Some common assumptions about procedures ‘Fully documented step by step procedures need to be actively referred to when

1. OPERAOptimising Procedures for Efficiency and Reduced AccidentsA systematic Approach to writing better procedures by involving the workforceDr David EmbreyManaging DirectorHuman Reliability Associateswww.humanreliability.com

2. Some common assumptions about procedures‘Fully documented step by step procedures need to be actively referred to when all tasks are carried out’ • The type and level of detail depends on the level of expertise for the specific operators and tasks concerned • Familiar, simple tasks usually do not require written procedures at the point of use • The Matrix provides guidelines for the appropriate form of procedural support • Risk, complexity, frequency of task performance

3. ‘You cannot write procedures for everything’ • For routine situations OPERA allows best practices can be defined and documented as the most cost effective way(s) of carrying out the task • For abnormal situations, job aids must be provided for dealing with situations that can be anticipated • For high risk, unpredictable situations, need to define generic procedures to get the system to a safe state and buy time

4. Three Phases of OPERA • Develop Best Practice • Participation not consultation • Reach consensus • Make Preferred Practice = Best Practice • Support Best Practice • Balance between job aids and procedures • Training & assessment linked to Best Practice • Maintain Best Practice • Maintain an open culture • Use feedback to update Best Practice

5. Control hazards identified in risk analysis Developed by consensus process • Reviewed by • Safety • Quality • Technical Specialists Based on preferred working practices Best Practice

6. Task step hazard analysis Formatting guidelines TaskAnalysis Criticality Screening Generate Task Inventory Document Current Practice Agree Best Practice Document Best Practice Operator Input Consensus Group (inc Technical Input) Risks Phase 1: Develop Best Practice Training needsCompetence assessment Level of support Tools Reference Procedure Stages Inputs

7. 7 Black books are a useful source of informal, undocumented knowledge

8. 8 Facilitators talk to all system users who describe current practice Practical realities Differences Facilitator(System user peer group) Task ExpertsPeople who do the job Technical questions Proposed best practice Consensus group I see a problem Job aids Training specification Best Practice Agreed by all Technical experts Risks controlled How the Consensus Process Works

9. Facilitator collects information and develops provisional best practice Reviewed by each shift & modified if necessary

10. Reference Procedure format Task analysis information Potential hazards / consequences Training issues

11. Maintaining Best Practice • Encourage and use feedback from users • Maintain channels of communication with the sharp end via facilitator • Reapply OPERA to generate new practices and supporting job aids & refresher training: • plant/equipment changes • changes in working practices • operational experience • regulatory change

12. What are Job Aids? “Any source of information used to support the successful performance of tasks”(e.g reminders and memory aids) Intended to complement but not replace skill

13. How often are written procedures actually needed ‘in hand’ when a task is performed?

14. 14 The Matrix for determining appropriate level of support Low Medium High Task Criticality Freq Infreq Rare Freq Infreq Rare Freq Infreq Rare Task Familiarity NWI NWI NWI NWI NWI JA NWI NWI JA Low Task Complexity NWI NWI NWI NWI NWI JA NWI JA SBS Medium NWI NWI JA NWI JA SBS JA JA SBS High No Written Instruction required (NWI) Job Aid required e.g. checklist/memory aid (JA) Step by Step instruction required (SBS)

15. Examples of Job Aid Formats • Step-by-step lists • Posters • Flow charts • Labels • Simplified drawings • Decision tables • Check list sheets

16. UK Plug Cover Job Aid E 13A 6mm Green & Yellow or Green L L 6mm 32mm Fitted With BS 1362 13A Fuse Always Fit BS 1362 Replacement Cartridge Fuse Fuse Brown or 22 Red mm N 12mm 6mm Blue or Black Cord Grip

17. Wasted fuel Target range Emissions Increase air Unsafe. Increase air gradually 6% Very unsafe. Do not increase air 5% 2% 1% Furnace /Hot Oil - Label Flue gas O2 • Maintain burner pressure above 0.6 bar • Keep oil temperature 170 - 225C

18. 18 Furnace Trip More than 1 hour Reset Alarms Identify initiator event Temporary unit shut down Attempt to re-light furnace Less than 1 hour Reduce feed Column temperature and reflux to manual Commence furnace start-up procedure Stop hot oil to columns 5 and 7 Bypass column 6 steam raisers Reset 98-DEA-80 Light pilot flame Stop tank 7 and 8 import Rundown to off grade Yes Is hotoil temperatureabove150°C? Did pilotflame light? No No Maintain column levels Reduce column reflux rates Yes Stop overhead pumps as condenser levels fall Return Unit to normal How longis furnace likely tobe down? Furnace Trip Job Aid

19. Low Medium High 1 Criticality Base initially on decision aid table Freq Infreq Rare Freq Infreq Rare Freq Infreq Rare Familiarity NWI NWI NWI NWI NWI JA NWI NWI JA Low NWI NWI NWI NWI NWI JA NWI JA SBS Complexity Medium NWI NWI JA NWI JA SBS JA JA SBS High 2 Get all the potential users together 3 Base final decision on what users want and need - listen to feedback! Planning Job Aids

20. Case Study Improving Procedures Compliance at a Major Multinational Chemical Site • Failure to manage flare line incident almost led to a catastrophic failure • Analysis of incident showed that main cause was failure to comply with procedures (HSE investigation) • HRA asked to investigate and propose solutions across site (~1000 employees)

21. Case Study Improving Procedures Compliance at a Major Multinational Chemical Site • Phase 1: Procedures culture survey developed and applied across site • Phase 2: Procedures culture change process OPERA (Optimising Procedures for Efficiency and Reduced Accidents) developed and piloted across site • Phase 3: OPERA rolled out across all production units on site over 4 year period (Owned by workforce, facilitated by HRA)

22. Procedures are not used because… % agree Don’t understand why they are necessary 40% More difficult to do work 42% Instead rely on skills & experience 72% Find a better way of doing them 42% Too long if followed to the letter 62% Too restrictive 47% Experienced people don’t need them 19% Too time consuming 44% Resent being told how to do job 34% No policy on when should be used 37% Assume have knowledge 70%

23. 23 Most procedures manuals were rarely accessed

24. Results of applying OPERA over a 3 year period Changes in opinions of workforce Opinions: Procedures are… Improvement over 3 year period Unworkable  +52% Not best practice +19% Too complex +21% Identification difficult +17% Not aware they exist +18% Don't understand why they are necessary +52%  Statistically significant changes

25. Case Study ConcludedWas the process successful? • Plant start-up time substantially reduced, giving ~500,000 pounds saving in first year • Many cost reductions due to reduced time needed to conduct yearly start-ups/shutdowns • Generally procedures followed as documented

26. Case Study ConcludedWas the process successful? • Reduced effluent emissions • Improved safety record • After 5 years savings of ~3 Million pounds produced • Site now has the highest production levels per employee of any site worldwide (Formerly bottom of the international league table)

27. Summary of Recommended Strategy • Start with the most critical tasks (from Task Inventory & Criticality analysis) • May use existing procedures as starting point but need to verify against actual working practices • Develop Reference Procedures for the Critical Tasks (depending on resources) • Develop Job aids, training and competency specifications to control risks • Proceed to other tasks as resources become available

28. 28 Real Men Don’t Use Procedures!