232: SPAC Recently Changed

Node SPAC Recently Changed

Definition/Typical Issues

Had standards or directives been recently changed? Did information concerning changes fail to reach all levels of the organization? Had some confusion been created by the changes?

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

  • The policy on calibration of flow indicators was recently changed. All of the maintenance department supervisors were briefed about the change, but the mechanics were not told of the change. As a result, the policy was not implemented as required.

Example 2

  • A new policy was put in place to require personnel to enter the time charged against each work order into a computer system. No one was told of the requirement or taught how to enter the information in the computer. As a result, the requirement was not implemented.

Typical Recommendations

  • Ensure that all levels of affected employees are aware of SPAC changes.
  • Verify that employees fully understand recent changes before expecting them to implement the changes.
  • Ensure that there is a process for communicating SPAC changes to the individuals who need to know about the changes.

Cross-References

Version 10 Element(s)
Node ID Node Name
70 Recently Changed

 

RBPS Element(s)
Process Safety Culture

 

Maritime Element(s)
Node ID Node Name
264 Recently Changed SPACs
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