228: SPAC Confusing or Contradictory

Node SPAC Confusing or Contradictory

Definition/Typical Issues

Were the SPACs confusing, hard to understand or interpret, or ambiguous? Were the SPACs incomplete or not specific enough? Did contradictory requirements exist? Were some requirements violated or disregarded in order to follow others? Was a SPAC not followed because no practical way of implementing the SPAC existed?

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 plant policy indicated that all "fatigue-related failures" be reported to the Equipment Reliability group. However, the maintenance organization had no guidance on what sort of failures were "fatigue-related." In addition, a recent reorganization resulted in the elimination of the Equipment Reliability group, and their previous functions were split among four other groups. So, it was unclear who the failures should be reported to.

Example 2

  • A release of a flammable liquid was larger than expected, overflowing the tank's dike. Administrative controls on the maximum intended inventories for the tanks in the dike were violated because of an anticipated shortage of the material from the supplier. Production had a policy of "stocking up" on materials whenever supplier issues were encountered, even if inventories exceeded the administrative inventory levels.

Typical Recommendations

  • Solicit comments and recommendations from operations, maintenance, and other personnel regarding ambiguous or unclear language in the SPACs. Resolve comments.
  • Ensure that policies regarding production, material control, procurement, security, safety, etc., do not contradict each other.
  • Provide the proper balance among safety, production, quality, reliability, and security.
  • Communicate to personnel that safety should be given top priority.
  • Ensure that SPACs reflect management's decision to make safety a top priority.
  • SPACs that require specific authorization signatures should state alternate sources of authorization in the event that the primary authorizers are not available.
  • Provide the necessary tools/equipment features to allow/encourage personnel to follow the SPACs.
  • Establish owners of each of the SPAC documents.

Cross-References

Version 10 Element(s)
Node ID Node Name
61 Confusing, Contradictory, or Incomplete

 

RBPS Element(s)
Process Safety Culture

 

Maritime Element(s)
Node ID Node Name
259 Confusing, Contradictory, or Incomplete
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