I am always perplexed when I visit a site that does not enforce strict compliance with approved procedures.
From the Physical Plant Operations Handbook:
“Without rules and guidelines, organizations are doomed to failure from their inception. To assure their continuity, religions have their holy books, athletic teams, their playbooks and we have our [Standard Operating Procedures].”
So, why wouldn’t an operator feel compelled to use their “playbook” procedures?
The most common answer I get is: “The procedure doesn’t work.”
Why doesn’t the procedure work?
“This valve is stuck,” or “This switch is jumpered out because it sticks.”
Maybe this seems like a legitimate excuse not to use the procedure – except why not write a temporary procedure that addresses the issue and still allows the system to function as intended?
“Well, trying to get a procedure changed takes too long – it’s too hard – I can make the system work now if I just…”
The trouble with an operator/shift creating an impromptu procedure is that the system is very likely to be turned over to the next operator/shift operating in an unknown condition. When equipment is operating without the knowledge or consent of the operator, the equipment is, by definition, operating out of control (Howlett II, 1996).
Only those with a thorough understanding of the effect on the entire plant should make procedural updates, even if it takes longer.
In the Industrial Operator’s Handbook, the author states:
“When correctly developed…system procedures have a lineage that can be traced back to the design basis of the equipment.”
Plants should make changing a procedure easy to avoid the temptation to create field alterations or deviations from in place procedures. If it is easier to cheat than to do something correctly, many will take the easy path resulting in potentially disastrous incidents.
One of the root causes of incidents is procedural violations. Frequently, several innocuous workarounds (i.e., field modifications to procedures) compound to form accidents. Emphasize to your operators that their immediate actions are based on a properly functioning system in a known condition. If operators make field alterations to equipment or procedures, their efforts may not be able to place the plant into a safe condition.
The benefits multiply for the manager if a simple, clear path to updating procedures exists: