Know when to not follow safety procedures
Safety professionals live by standards and procedures on a day-to-day basis, but when an incident happens that doesn’t follow the books, sometimes following the plan has to go out the window.
“What is good operational discipline?” Steve Cutchen, investigator at the Chemical Safety Board (CSB), asked during his presentation entitled “Operational Discipline Does Not Mean Following Procedures” at the Innovation Days 2019: Foxboro and Triconex User Groups event in Austin, Tex. “The performance of all tasks done correctly every time. There is a dark side. It can lead to blame tasking. What does correctly mean?”
Therein lies the issue of when to follow procedures and when do you have to go above and beyond what is in the book.
That is because when there is a safety incident real situations are unplanned, unanticipated and have no established accurate procedure. In addition, real situations can be complex where procedures cannot be prepared in advance.
In quite a few instances when people following procedures, they end up suffering from a subjective judgement based on outcome bias. If the outcome was good there would be one reaction, but if the outcome was bad, there could be real problems.
In addition, there is hindsight bias, where people look at the event in a vacuum and not as it was unfolding, that ends up being the basis for blame.
Following procedures are good guidance when operational cause and effect have been anticipated where work as imagined matches the work as done. But the issue is, that does not happen all the time.
“There are three gaps,” Cutchen said.
- Work as imagined conflicting with work as done
- Abnormal operations
- Complicated tasks vs. complex tasks.
“Work as imagined vs. work as done is based on assumptions explicit to what you think procedures should be executed,” Cutchen said. “The problem is, it may not actually work out that way.”
There could be other factors that come into play like situational factors when people multi-task or different skill sets of people doing the work.
“When work as imagined matches work as done, apply the chosen good practice so you have it covered,” Cutchen said.
He also mentioned abnormal operations which are unplanned and unanticipated, where there are no established accurate procedures. “How will operational discipline help in an abnormal situation? Cutchen asked.
Then he talked about complicated tasks vs. complex tasks. A complicated task is imagined ahead of time. Situational hazards are identified. Meanwhile, a complex task is not imagined ahead of time; an unrecognized situation.
Cutchen discussed three well-known safety incidents that related to the three gaps.
1. Work as imagined vs. work as done: BP Texas City where a fire and explosion occurred during a start-up operation at the refinery.
In this case, among the multitude of issues was the work that was imagined was a clean use in instrumentation during start up, but what was really happening is worked ignored the instrumentation that said the distillation column was filling up and it eventually overflowed creating a vapor cloud of flammable gas which caught an ignition source, killing 13 and injuring 180.
2. Abnormal operations: Chevron Richmond, Calif., refinery pipe rupture where 18 workers were caught in vapor cloud and all but one escaped and one was caught in the vapor, but was able to get out. There were only 6 minor injuries. In addition, 15,000 members of the public sought medical attention.
3. Complicated task vs. complex task: DuPont LaPorte, Tex., toxic chemical release that left four dead and five others severely injured.
Following procedures are not the way to go when one of the gaps comes into play.
“In these situations, workers adapt and recover, they are the source of safety,” Cutchen said.
It is not all doom and gloom, though. A company can succeed in protecting itself from one of the safety gaps by:
- Verifying and updating checklists every time they are used. Make them best practices
- Actively converge work-as-imagined (procedures) and work-as-done (implementation)
- Eliminate outcome bias from near miss reviews of cause where you treat near misses as gifts; investigate and use the results, what was different this time
- Eliminate hindsight bias from investigations: Not just what happened, but why? What made sense at the time?
Companies need to implement a resilience mindset where the organization recognizes people stop incidents from occurring, where there is involvement in developing a team-based conduct of operations, and predetermine abnormal response authorities, safety constraints, and stop work conditions
“There needs to be more than just following the procedures,” Cutchen said.