3: Front-line Personnel Issue
Definition/Typical Issues
Was there a difference between the desired performance of front-line personnel and their actual performance?
If the causal factor is a front-line personnel performance gap, then coding under this node is appropriate. If the causal factor is an equipment performance that is directly caused by a front-line personnel performance gap, dual coding under this node is appropriate (for example, if a bearing failed (EPG) because it was installed incorrectly (error by front line personnel, then dual coding under nodes 2 and 3 are appropriate).
Note 1: Personnel issues include instances where personnel fail to perform as desired, even if they follow the procedure. If an individual follows an incorrect procedure precisely, there is still a performance gap because the individual does not perform the task in the desired manner.
Examples
Example 1
- A tank overflowed, resulting in a spill to the environment. The operator filling the tank was using the wrong revision of the procedure. It had an incorrect calibration chart for the tank.
Example 2
- A mechanic performing maintenance in a confined space was not allowed to take a written procedure with him. As a result, he had to review the procedure and commit it to memory. During performance of the task, he omitted an important step. This resulted in the failure of a key piece of equipment.
Example 3
- An operator made a mistake performing a calculation. The data used in the calculation came from multiple steps in the procedure. She made a mistake in transferring one of the data points from an earlier step in the procedure to the step at which the calculation was performed.
Example 4
- A contract employee took a sample from product tank C instead of product tank B. The tanks are arranged from left to right: A C B.
Example 5
- A company employee made a mistake using a scale to weigh a pallet of material. It was the first time the operator had used the scale. He was told how to use the scale as part of training, but had never actually used it.
Typical Recommendations
- Ensure that third-party personnel do not have access to equipment that they are not qualified to operate.
- Ensure that contract employees have sufficient guidance to perform their activities.
- Ensure that personnel have sufficient guidance to perform their activities.
- Ensure that personnel are trained on all aspects of the job, including unusual and one-of-a-kind equipment.
- Develop equipment and procedures with the end-user in mind.
- Provide appropriate supervision for personnel.
- Ensure that performance standards are understood by personnel.
- Reward appropriate behaviors.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 3 | Personnel Difficulty |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 4 | Human |