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Twelve Things Operations Managers Can Do To Get Everyone To Follow Procedures Every Time

P.M. HaasConcord Associates, Inc.www.concordassoc.com

1. Write it down. Document procedure usage policy and demonstrate unequivocal management support. Specify responsibilities of management and of everyone involved in development or use of procedures. Clearly lay out consequences – potential safety impacts, compliance violations, workplace injuries, lost production, and yes, disciplinary action - for not using procedures appropriately. Provide training/information sessions on specific corporate or industry incidents for which inadequate procedure use was identified as a causal factor. Demonstrate personal emphasis during plant walk-downs and informal sessions with workers.

2. Get rid of old “notions”. In many facilities, new operators absorb from their trainers, peers, and supervisors the notion that procedures are written primarily for training purposes. Having to refer to procedures (especially step-by-step procedures) once “qualified” is a clear sign of weakness – inexperience, lack of knowledge, lack of confidence. A more powerful concept is that procedures are primarily a tool – an “operator aid” - used by a qualified, competent operator to help avoid errors that plague all human endeavors. Typical procedure errors include failure of short term or long-term memory, losing focus when interrupted, attention to detail during long tedious tasks, etc. Good operations still depends good operators. Using a procedure is in no way a substitute for operator knowledge or skills, but rather a tool to help knowledgeable, skilled, well-trained operators assure accurate, timely, consistent task performance every time.

3. Get supervisors on board. One of the strongest influences on operator performance is supervisory expectations and attitudes. Nothing will undermine well-designed management policy or derail performance-improvement efforts more quickly than a supervisor who doesn’t really buy into it and demonstrates the lack of agreement/confidence through attitude, lack of enforcement, lack of positive reinforcement, or overt orders contradictory to stated policy. Often Change Managers find that “mid-level management” presents stronger resistance to change than upper management or first line operators. They tend to have the most “emotional capital” invested in the status quo, and feel more threatened by change than the others. Commitment of supervisors and field managers is critical to creation of the disciplined safety culture that supports 100% procedure compliance.

4. Spell out the specifics. Provide detailed written guidelines/requirements for usage. Each type of procedure – operating, maintenance, administrative, engineering standard, etc. – has a different purpose, different user characteristics, and different usage environment. Give specific detailed guidance for how/when management expects each type of procedure to be used. With regard to operating procedures, categorize them by usage, e.g., “reference” or “use every time” and clearly define the meanings of those categories. We recommend a “risk-based” assessment in which tasks that are more complex, are performed less frequently, or for which failure has more severe consequences require the procedure to be followed “in-hand”, step-by-step every time the task is performed. The most critical tasks may require signature upon completion, checking off each step, or in some cases initialing each step as it is performed. Rules for use of normal, abnormal and emergency-response procedures will likely differ. For example, an operator would be expected to perform immediate abnormal-response actions without procedure in hand, but after stabilizing the situation may be required to use the procedure in hand to check immediate actions and proceed to recovery. Set

Copyright by Concord Associates, Inc., 2002All rights reserved. May not be reproduced in any form without permission of the author.

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specific rules for using each type and category of procedures, conduct training on those rules, and enforce them. Note that classifying a procedure as “reference” does not imply any relaxation of procedural compliance. Reference procedures should be written in exactly the same format as use-every-time procedures and, just like use-every-time, performed exactly as they are written. An operator could pick up a reference procedure and follow it step-by-step if he/she chooses to do so. And, if the operator chooses to not use it in-hand, the working standard of performance is that a knowledgeable observer with the procedure in hand would see every step performed correctly.

5. Make them reliable. Technically incorrect or out-of-date procedures will destroy operator confidence in procedures, and if it occurs repeatedly, procedures will not be used. Implement a formal “technical verification” program that documents and maintains the technical basis for every operating procedure. Make sure that what’s in the procedure, step-by-step, is the correct action. For example, verify that all parameter values/limits, etc. are correct and the technical basis for them is documented. Verify that order-dependent steps are written in the correct order, and that all appropriate abnormal response conditions/ actions have been addressed. Implement a formal process for correcting procedures found to be in error, and make those corrections promptly. Require an appropriate level of technical verification to be a part of the Management of Change process for changes in procedures.

6. Make them accessible. It won’t do much good to have great procedures if operators can’t get them to where they need them when they need them. Having procedures on the computer network can greatly increase efficiency of document management and shorten time for upgrades. But it won’t help much if operators don’t have easy access to the net, if the network is unreliable, or the software doesn’t present a specific procedure promptly, easily, in a way that is logical/natural to operators. Operators should have immediate access to procedures as close to the actual work site as reasonable. In addition, procedures need to be in a form appropriate for performing that task under all anticipated conditions, taking into account, for example, equipment accessibility, environmental conditions, protective clothing or working in hazardous/controlled areas.

7. Foster “Thinking Compliance”. The goal is to have good procedures and then have every operator follow them precisely every time the task is performed. However, no procedure can predict every possible operating condition, and there may arise times when a good procedure is not valid or requires an action that, under the conditions, is unsafe. Operators should understand that they are accountable for taking the correct action. While 100% compliance is the goal, “blind compliance” is not desired. Part of an operator’s responsibility is to understand the systems and process well enough to identify and take appropriate action (or cease all action) regardless of what the procedure says. Similarly, operators should be encouraged to continuously question and challenge the accuracy and effectiveness of procedures and recommend modifications as necessary. This can be a difficult line for operators and managers to walk. The operator hears, “I want 100% compliance with procedures, but I will hold you accountable if something bad happens because you followed a procedure that is wrong for the conditions at hand.” Nonetheless, it is management’s responsibility to clarify expectations and accountability and to hold operators accountable (as well as to create an environment in which everyone feels ownership and accountability as part of a team performance). Besides creating the “questioning” attitude, a critical factor is to not only document, but to demonstrate day-to-day, that management’s need for productivity will never override its commitment to safety. In the face of uncertainty, it is always proper and expected for an operator to sacrifice productivity in favor of safety.

8. Practice “User-Centered Design”. – There are many human factors design issues that need to be addressed in the design of procedures. The fundamental principal is “user-centered design,” i.e. design the tool to fit the person who will be using it. Since

Copyright by Concord Associates, Inc., 2002All rights reserved. May not be reproduced in any form without permission of the author.

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procedures are an on-the-job aid for humans performing a task, design needs to take into account all of the pertinent characteristics of the human user and the environment in which the task is performed. The goal is to it to make it easy for operators to follow procedures correctly and difficult for them to make an error. There are potentially a huge number of human, task, equipment, and environmental characteristics that are considered by human factors specialists in the design of technical documentation. Page layout, sentence structure, treatment of “Cautions” and “Notes”, handling of branching, and location aids, are a few of the more obvious of the many, many features that can be improved to reduce the likelihood of common human errors. Fortunately, many of the “best practices” of procedure design and writing have been garnered from the human factors literature and compiled in different industries and Federal Government agencies. The Center for Chemical Process Safety (CCPS), for example, has published “Guidelines for Writing Effective Operating Procedures” for the chemical process industry. Gather and review several such sources and adapt them to your specific needs. Then formalize a procedure writers guide, require its use, and require independent review for compliance with the guide.

9. Test before using. A key part of user-centered design is usability testing. As noted above, there is an enormous number of factors that can influence likelihood of human error or success. No matter how good your writers guide and procedure writers are, there will be some glitches, some of which could directly lead to an error or discourage use. Before the procedure is approved for use, take it out into the facility where it will be used. And, don’t just send an experienced operator out alone with the procedure to “walk it down”, especially without training on what to look for. Like all of us who mentally “automate” things we do very frequently, the operator will not “see” the potential problem. Assign a recently qualified operator with a procedure writer or trained observer. “Walk through and talk through” procedures and look for clarity of meaning, ease of use, and situational conditions that can render the procedure ineffective. For example, are the terms and equipment identification used in the procedure clear and consistent with what is used in the field? Can the operator physically access the equipment or instrumentation the way that writer expected, under all conditions? Accessibility (physical, visual, or audio) may be limited as a result of an abnormal condition, use of protective clothing, inadequate lighting, inclement weather, etc. If a series of steps in a procedure is not order-dependent, why make the operator walk back and forth across the work area to do them in the order they’re written? Operators will begin to “work around” procedures that are hard to use, and that will encourage an attitude that it’s OK to not follow procedures precisely if you know what you’re doing. Whenever its possible, change the procedure to match normal, common sense human behavior rather than vice versa.

10. Tightly control changes. Most facilities have established processes for formal review and approval of significant procedure changes, such as rewrites necessary due to equipment or process modifications. It is also important to establish clear and specific requirements for marking temporary changes in the field, use of temporary procedures while the review and approval process is in progress, appropriate notification of field changes made, and even exactly how procedures should be “redlined”. Extremely important are precise requirements for action and notification of supervisor/co-workers if the procedure must be suspended while an operator is using it. Example reasons for suspension are because proceeding would be unsafe, prerequisites have not been met, valves or other components are found in a position other than expected, or some other abnormal condition exists. Authority for field changes, responsibilities, notification requirements, and specific rules for making changes and for use of changed procedures need to be clearly documented.

11. Train everyone. Recognize that designing and writing procedures is a craft. Like technical training or operating a facility, it takes some specialized knowledge, skills, and aptitudes, plus some experience. While technical knowledge about operations is

Copyright by Concord Associates, Inc., 2002All rights reserved. May not be reproduced in any form without permission of the author.

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essential, not everyone who has been an operator can write good procedures. A comprehensive, detailed writers guide and an effective review process can help a lot, but anyone assigned to write procedures should be taught how to apply the procedure writers guide. And, operators need to be trained to apply the policies and processes described above. Those policies and processes will be ineffective if the people out in the plant don’t understand them and buy in to them. Don’t leave the training function to “osmosis” by way of on-the-job experience, where operator attitudes and behaviors are determined by how their peers and immediate supervisor “have always done it”. Provide formal training on the overall procedures policies and usage requirements. In addition, be fanatic about instructors following procedure usage requirements and best practice during the normal course of initial, OJT, and re-qualification training.

12. Make someone the owner. While every operator is responsible and accountable for following procedures, someone has to “own” the procedures process. Someone has to be focused on managing, supporting, controlling, and evaluating the entire procedure process. At some facilities it is very difficult to answer the question, “Who is responsible for developing procedures?” Usually, somebody reporting to the training manager has “acquired” a leading role, but responsibility for the process is spread diffusely through training, operations, maintenance, technical support, and other organizations. Processes usually don’t remain effective for long if someone isn’t responsible for maintaining them.

Copyright by Concord Associates, Inc., 2002All rights reserved. May not be reproduced in any form without permission of the author.