231: Unaware of SPAC

Node Unaware of SPAC

Definition/Typical Issues

Were standards, directives, or policies not communicated from management down through the organization?

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

  • During an extended facility outage, routine surveillances of process alarm panels were not performed. As a result, a chemical leak went undetected for 2 days. Facility management had not communicated to first-line supervisors that normal surveillance procedures remained in effect during the outage.

Example 2

  • The corporate reliability group set up a database to capture field problems. However, facility personnel were not made aware of the new system. As a result, the database was not populated.

Example 3

  • A standard was in place that addressed the use of storage racks. The standard was not applied because personnel were unaware it existed. As a result, the storage racks were undersized.

Typical Recommendations

  • Review the contents of relevant SPACs during initial and refresher training; assess employees' understanding.
  • Periodically stress the importance of using SPACs during shift-change meetings, safety meetings, etc.
  • Ensure that SPAC documentation is readily available to all affected employees at all times.

Cross-References

Version 10 Element(s)
Node ID Node Name
69 Communication of SPACs LTA

 

RBPS Element(s)
Process Safety Culture

 

Maritime Element(s)
Node ID Node Name
263 Unaware of SPACs
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