226: No SPAC or Issue Not Addressed in SPAC

Node No SPAC or Issue Not Addressed in SPAC

Definition/Typical Issues

Was there a failure to develop a SPAC to control the particular type of work or situation involved in the incident? Was the work or situation significant or complex enough to warrant some type of SPAC to ensure adequate job quality and work control, but none was developed? Did the SPACs fail to consider all possible scenarios or conditions?

Note 1: In addition to the node number, the company- or facility-specific SPAC may also be coded in the trending database to aid in trending of causes. For example:

  • If the root cause is the No SPAC or Issue Not Addressed in SPAC (#226) node; and
  • The issue is that the facility's procedure guidelines (say it's plant policy AD-01.7) only requires field validation of safety-related procedures, but not quality-related procedures; and
  • As a result of a procedure error that could have been corrected during field validation, unacceptable product was sent to a customer.

In addition to coding the root cause of No SPAC or Issue Not Addressed in SPAC (#226), AD-01.7 should also be entered into the trending database. This will allow the facility to specifically identify the SPAC that is associated with each root cause.

Examples

Example 1

  • A maintenance worker was exposed to a pressurized release of a process material. The line from which the material was released had not been depressurized and cleared before maintenance work began. The plant did not have a general safe work practice/permit for opening process equipment (i.e., "line breaking").

Example 2

  • An operating procedure was not field verified. Company policy did not require field verification procedures. As a result of the procedure error, unacceptable products were shipped to multiple customers.

Typical Recommendations

  • Compile a list of SPACs mandated by regulatory requirements (OSHA, EPA, etc.) and compare it to a current list of existing SPACs. Develop any missing SPACs.
  • Provide written documentation of SPACs.
  • Define, document, and communicate missing SPACs.
  • Define core organizational values in SPACs.
  • Develop a comprehensive list of applicable codes, standards, and guidelines that the facility must comply with.
  • Establish owners of each of the SPAC documents.

Cross-References

Version 10 Element(s)
Node ID Node Name
59 No SPACs

 

RBPS Element(s)
Process Safety Culture

 

Maritime Element(s)
Node ID Node Name
257 No SPACs/Issue Not Addressed
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