Procedure Use and Adherence is really two tools in one – Sticking to the procedure and how you use it are the key factors here. Working on the wrong revision, losing your place, or not following up to see if there is a procedure to perform the task you are doing are just three examples of the many different kinds of mistakes that can be made. A lot of issues can be prevented by finding the correct procedure (meaning the proper revision) and then following it with an “engaged” mind… which means not blindly going step by step (ala cook-booking). Unfortunately, some people are being trained to perform procedures, and don’t fully understand the mission or the equipment that they are either fixing, testing, or simply making sure works properly. Your mind must remain thoughtful throughout the evolution to comprehend what the procedure steps are trying to accomplish. Only then can you recognize when something is going wrong. Along with this tool (in another post), there will be a discussion on a situational awareness questioning attitude tool called “OOPS” – Out Of Process or Parameters, which can be directly applied when performing a procedure. It’s just another mechanism to get you to stop the job and regroup.
So ask yourself – why do we need procedures in the first place?
Procedures help users to perform activities correctly, safely, consistently, and in accordance with design requirements. Procedures direct people’s actions in a proper sequence and minimize reliance on one’s memory and the choices made in the field. When workers are forced to interpret a procedure’s use and applicability, the chance for error is increased.
Procedure use specifies the minimum required references to the procedure during the performance of a task, such as continuous use (in-hand), reference use, and information use. This really speaks to how one uses the procedure. Are you continuously referring to it in hand, constantly and methodically checking through each step at the job site, or is it a procedure of how to do something that only occasionally needs to be referred? These are the different ways to “use” a procedure. At nuclear stations these are denoted as “levels of use” and come in 4 varieties:
- Information (could be on hand, or in the library)
- Reference (at the job site)
- Continuous (in hand)
- Multi-Level (sections of the procedure are a combination of the above levels)
Procedure adherence means following the intent and direction provided in the procedure regardless of the level of use.
Procedures incorporate the policies, operating experience (lessons learned), effective work practices and management decisions about how a task is to be performed. Technical procedures are written to direct desired behavior for the various complex and technical work activities that will affect plant equipment. However, experience has shown that technical procedures may not always contain sufficient information for the user. With turnover of the workforce, less experienced workers take the place of more experienced personnel. The quality of the procedure (technical content and usability) is paramount, especially if the task involves risk, significant systems or components. Therefore, feedback from the user on the quality of procedures and work orders is highly desired. This feedback is most appropriately shared at a post-job critique, unless the procedure quality was such that it could not be performed as written, and then the task would need to stop and the procedure updated immediately before continuing. Note that this is in a highly regulated environment, and may not apply to all types of work involving procedures.
When to use the tool
Procedures are to be used for activities that involve manipulation, monitoring, or analysis of equipment or physical work.
How to use the tool
- Verify the procedure being used is the correct revision. Procedures are corrected and approved before use.
- Review all Prerequisites, Limits, Precautions, and Initial Conditions before starting work.
- An effective place-keeping method is used for procedures that do not require sign-offs. At least, initial or check each step complete, after the action is performed, before proceeding with the next step. (Place-keeping is another branch of this tool and will be discussed in another post.)
- Procedures shall be followed as written without deviating from the original intent and purpose.
- Do not deviate from the sequence of steps, unless approved.
- Do not ‘N/A’ any step, unless approved.
- If a procedure is incorrect, will result in damage to equipment if used as written, cannot be performed as written, will result in incorrect parameters or configuration, or is otherwise unsafe, then STOP the task and contact a supervisor.
- If desired or anticipated results are not achieved, STOP, do not proceed, and contact a supervisor.
At-risk behaviors to avoid
- Assuming a procedure is well-written and accurate
- Cook-booking a step or procedure (blind compliance) without understanding its purpose
- Performing a task without knowing or understanding critical steps in advance
- Believing in the philosophy that, “Any operator worth his/her salt doesn’t need a procedure.”
- Skipping steps or segments of a “routine” procedure, since those steps have been unnecessary in the past
- Not rigorously following a procedure because of personal past success with the task
- Interpreting the procedure in a way that knowingly does not meet the intent
- Commencing a procedure without establishing initial conditions required by the procedure
- Using a procedure maliciously, knowing it has flaws
- Not reviewing an unfamiliar procedure (or lacks proficiency) before performing a task
- Using a previous revision (superseded) of a procedure
- Marking steps “N/A” for those that are inadequately or improperly written
- Not submitting feedback on procedure problems (technical accuracy and usability)
- Not applying some form of place-keeping for continuous use procedures
- Using check marks instead of initials or signatures for continuous use procedures, unless the procedure specifically allows it
- Ditto marks (“)
- One set of initials followed with a line through remaining signoff blanks
- Signing off a step as completed before it is complete
With much gratitude, a lot of the above HPT basis comes from Department of Energy (DOE) and Institute of Nuclear Power Operations (INPO) research and collaboration, and the source document could be found by clicking here.
This article (you would have to purchase – sorry, it’s not free to share) adds some more specificity to the discussion : Engaging Workers as the Best Defense Against Errors & Error Precursors by Jan K. Wachter and Patrick L. Yorio
Me. I’ve inserted a few twists and clarifications for users and myself.
[As a reminder – don’t forget to click the graphic at the top of each post for an Easter egg!]