3134 Human factors briefing note no. 6 – Safety critical procedures

Overview:

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Procedure: written instruction describing how to carry out a job of work. May be on paper, including diagrams, flowcharts etc, or be presented on a computer screen – this briefing note focuses on safety critical procedures but the principles apply to all procedures. Safety critical procedure: describes a procedure for a task which, if carried out incorrectly or not at all, could lead to serious plant damage, loss of containment, injury or fatality.

Why procedures?

“There have been numerous recorded incidents where failings by operators have been the major contributing cause of major accidents. Provision of clear, concise and accurate operating procedures is the most effective measure to prevent, control and mitigate such events…Adequate training should be provided to ensure that operators are fully conversant with written procedures.” Source: HSE COMAH web pages http://www.hse.gov.uk/comah

Documented procedures are required as part of a safety management system. If they are difficult to use or if there are other problems with them as described in this briefing note, then it’s likely that the system for producing procedures is at fault and needs to be overhauled. Procedures are not required for all tasks but are most useful for difficult or infrequently performed tasks (start-up/shutdown, emergency, key maintenance tasks) they provide a consistent and safe means of performing tasks, and they are useful in training.

Failure to comply with procedures typically arises not because of their users’ attitudes or ignorance but because of faults with procedures themselves, for example: they are poorly-written, difficult to find, not logically structured, contain assumptions (e.g. ‘re-assembly of the device is simply the reverse of dis-assembly’), or they do not cover unusual circumstances. Briefing note 12 is on the subject of human errors and violations – otherwise known as non-compliance with procedures or rules – and includes some useful further information and references on this subject.

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