November 9, 2005 | Mark Paradies

Procedure Useage – When will they learn???


One common theme (near root cause) I continue to hear in major accidents is:


Sometimes they were not using a procedure because no one had written one (so they were winging it). Sometimes there was a procedure but the operator, supervisor, or mechanic decided that they knew a better way. Sometimes the company culture is that “only trainees use procedures.” Sometimes people don’t understand that using a procedure means that you must read a step, do the step, and then read the next step, … (instead of “doing” a procedure from memory). I’ve even heard managers say that you CAN’T operate or maintain a plant by procedure – it just can’t be done!

When I talk about procedures, I’m not talking about policies. I’m talking about work related checklists and detailed written procedures that document how a job is to be performed on a step by step basis.

From the BP Texas City Refinery Explosion to Chernobyl, accidents happen when people don’t use procedures.

Look at the list of worldwide major accidents at:

and imagine how many could have been prevents if only the staff had used an accurate, well written procedure.

If proper use of procedure is such a big deal (and it is), why aren’t companies doing more to get operators and mechanics to use procedures?

What kinds of things should they be doing?

1. Investing in well written procedures that are thorough, yet easy to use.

2. Making the procedures more available for the plant staff.

3. Training people about the importance of procedure usage and what can happen when procedures are not used. This should include the human factors / psychology behind how procedures improve performance.

4. Conducting regular supervisor and management audits of procedure usage on all shifts.

5. Remote monitoring of operations (security cameras) so that procedure usage can be checked remotely.

6. Developing a rewards program for proper procedure usage.

Is your facility doing anything to ensure that procedures are being used?

If not, your company may be a candidate for the list of facilities who have had a major accident.

Don’t wait – get going! Start promoting procedure use today!

Root Cause Analysis
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