229: SPAC Incorrect
Definition/Typical Issues
Did technical errors or incorrect facts exist in 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 fire occurred when grinding near a process unit ignited vapors leaking from a nearby flange. The hot work policy for the plant erroneously indicated that a hot work permit was not necessary for grinding. Grinding was inadvertently deleted from the list of activities requiring a hot work permit during the previous revision of the policy.
Example 2
- The organization did not require any analysis of the parts handling practices for potential hazards. As a result, parts were being routinely damaged during handling operations within the facility. When the parts were stacked on tables, the weight would sometimes cause damage of delicate tabs on the parts.
Typical Recommendations
- Include SPACs in the scope/charter of hazard review teams.
- When errors are found, modify SPACs accordingly.
- Establish owners of each of the SPAC documents.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 62 | Technical Error |
| RBPS Element(s) |
|---|
| Process Safety Culture |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 260 | Technical Error |