227: SPAC Not Strict Enough

Node SPAC Not Strict Enough

Definition/Typical Issues

Were the existing SPACs not strict enough to provide adequate job quality or work control? Did vagueness allow violation of the intent, if not the letter, of the SPACs?

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 safety limit was violated during operation of a process because an alarm indicating a high temperature was bypassed. The first-line supervisor thought the alarm was false and bypassed it. The SPACs were not strict enough because they allowed the supervisor to bypass an alarm without getting any management of change review or approvals from management and technical support.

Example 2

  • Operators were supposed to check the operation of pumps by taking vibration readings and checking temperatures. Instead, the operators just performed a visual check of the pumps. The SPACs did not specify the level of detail required in procedures, and the SPACs did not require supervisors to periodically check on how the operators were performing their tasks.

Example 3

  • An operating procedure was not field verified. Company policy only required field verification of safety-related procedures. This procedure only had an impact on product quality. However, as a result of the procedural error, unacceptable products were shipped to multiple customers.

Typical Recommendations

  • Improve the level of detail of SPACs.
  • Improve the description of accountabilities in SPACs (for resolving ambiguities).
  • Define core organizational values in SPACs.
  • Establish owners of each of the SPAC documents.

Cross-References

Version 10 Element(s)
Node ID Node Name
60 Not Strict Enough

 

RBPS Element(s)
Process Safety Culture

 

Maritime Element(s)
Node ID Node Name
258 Not Strict Enough
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