233: SPAC Enforcement Issue

Node SPAC Enforcement Issue

Definition/Typical Issues

In the past, has enforcement of the SPAC been lax? Have failures to follow the SPAC in the past gone uncorrected or unpunished? Has noncompliance been accepted by management and supervision?

Note 1: Coding under the Rewards/Incentives Issue (#211) or Improper Performance Not Corrected (#193) nodes may be appropriate.

Note 2: 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 mechanic made a mistake installing a piece of equipment. He did not refer to a procedure when performing the test. Although the policy is to always refer to the procedure, the policy had not been enforced. Mechanics often did not take procedures to the work site, and their supervisors were aware of this.

Example 2

  • Operators were supposed to log local tank levels every 2 hours. However, they would typically take the reading only at the beginning of the shift. They used these readings to fill in the readings for the remainder of the shift. No one ever took issue with this practice until after an accident occurred.

Typical Recommendations

  • Management should set an example by always following the intent of the SPACs.
  • Employees who choose not to use the SPACs should be corrected and/or punished:
    • Discipline should be fair, impartial, prestated, sure, and swift
    • Enforcement needs to be consistent
  • Define core organizational values in SPACs.

Cross-References

Version 10 Element(s)
Node ID Node Name
71 Enforcement LTA

 

RBPS Element(s)
Process Safety Culture

 

Maritime Element(s)
Node ID Node Name
265 Enforcement Issue
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