SafetyInsights.org

Another on the issues of procedure use, based on survey of 72 operators in high-risk industries.

The main issues for proper procedure use related to outdated procedures and onerous procedures leading to information overload. On the latter, critical risks & steps were reported to be buried in onerous procedures. Issues also related to accessibility of procedures, the format, and providing either too little or too much info. Information overload was mentioned by about half of the interviewees as a contributor to abandoning procedures. Information overload was noted to result in key cautions, steps or risks getting lost in the details and thus, making the key info more salient was seen as positive by participants. Participants also liked the use of labelling and using pictures and diagrams to convey info. Operators also noted a disconnect between writers of the procedures, who didn’t understand the work, and the users (which was seen as non-transparent). Procedures are sometimes used purely out of fear for job security. Also noted was that many companies had a reactive approach to reviewing procedures, where this only happened after accidents (e.g. “written in blood”). Procedure use decreased as tasks became more frequent and repetitive, or as experience of operators grew. Interestingly, procedure use was not linked to the criticality of the task. Use of procedures by many came as a result of concern for job security or punishment from the organisation. Quoting the paper, “This phenomenon explains the procedure use even when perceived importance significantly drops as a result of repetition” (p10). Although many people did find complying with procedures to be necessary, it also resulted in frustration for people. The issue of blame was highlighted, said to drive a division in the organisational division and obstructing communication on critical info. Procedures for less frequent tasks were seen more positively by operators (and people generally felt safer using them), but rarely preferred for emergencies. With emergencies, operators would often view procedures afterwards to “validate” their decisions. Nevertheless, people generally felt safer when using procedures than not using them, where they were seen as safeguards in certain circumstances [Although linking to other findings in the paper, it’s also possible people “like” procedures heavily based on back-covering from the organisation if something goes wrong.] The abundance of different safety management documents, serving similar purposes, was seen to complicate procedure use. Moreover, different tools (JSAs, what-if cards and others) were seen to be overlapping in many areas and providing little additional value. Sites without digital access believed moving to digital would improve accessibility. Sites with digital systems generally liked them. However, most interestingly, digital safety systems (compared to physical documents), were reported to be misused – such that they can increase work for operators, due to the ease of assigning more checklist items and forms. On the above, one interviewee said: “[regarding handheld] instead of really fixing the issue at hand, they just throw more checklists at us to make sure we’re checking it. Instead of fixing the main problem” (p17). Document review processes could be a long-drawn out process, sometimes over years, where new info is added to older procedures. This may give the impression that the procedures have been refined over decades, but the “slow development offers another explanation for the reported problems of excess information, overencumbrance of documents, and outdated procedures, as writing procedures then attends to newer updates rather than evaluating the relevance of past instruction” (p11). Approximately a third of interviewees mentioned that there was a pattern of people not offering changes to procedures. Barriers were reported as uncertainty around the change process and a sense of complacency to procedures since practical knowledge is emphasised over procedure writing. Procedure revision processes were “handed off” to others in the organisation and were seen to be generally non-transparent. Authors: Farzan Sasangohar, S. Camille Peres, Jason P. Williams, Alec Smith, M. Sam Mannan, 2018, Process Safety and Environmental Protection Study link: https://doi.org/10.1016/j.psep.2017.09.010

Link to the LinkedIn article: https://www.linkedin.com/pulse/investigating-written-procedures-process-safety-data-from-hutchinson