HealthandSafetyExecutiveHealthandSafetyExecutiveProceduresWhyareproceduresneeded?COMAHSafetyReports‘allactivitiesareperformedinaccordancewithdefinedstandardsandprocedures’‘operatorsadheretowell-practicedwrittenprocedures’Whyaddressprocedures?•Contributiontoincidents–Mostcommonhumanfactorsrootcause–e.g.studyof130incidentsinUSrefineries•Bhopal•PiperAlpha•TexasCity•Others?Whyareproceduresneeded?•Tominimiseerror/mistakes•Toensurecriticalsafety/qualitystepsarecarriedout•Toprovideabasisfortraining•Toprotectagainstlossofoperatingknowledge(e.g.demanning)•Tostandardiseworkingpractice•TomeetstatutoryrequirementsCleansingServicesGroup,Gloucester•MajorfireonlowtierCOMAHsite(wastemanagementfacility)•Incompatiblematerialsnotseparatedorsegregated:–Initiationofincident–EscalationofincidentCSGfire,30October2000•ProceduresheavilyrelieduponasaprimarycontrolmeasureHowever:•Proceduresdidnotsupportthedecisionsthatstaffhadtomake•Inadequatemanagementofprocedures(Plan,Do,Check)•Humanfactorsexpertwitnessstatement•Fine£250,000pluscostsof£400,000Procedures:fitforpurpose•Notalternativetocompetence•Typesofprocedures:–Backgrounddetail–Step-by-stepwrittenprocedure–Jobaid(e.g.checklist,flowchart,diagram)•Useof‘BlackBooks’DetermininglevelofproceduralsupportLowLowMediumHighMediumHighFreqInfreqRareFreqInfreqRareFreqInfreqRareTaskCriticalityTaskFamiliarityTaskComplexityStepbyStepinstructionrequiredJobAidrequirede.g.checklist/memoryaidNoWrittenInstructionrequiredIsthetasksafetycritical?Isthetaskhighlycomplex?Isthetaskrarelyperformed?YESYESYESNONONOIstheuserinexperienced?Useastep-by-stepprocedureYESNODetermininglevelofdetailrequiredUseajobaid,suchasachecklist,diagramorflowchartJobAids“Anysourceofinformationusedtosupportthesuccessfulperformanceoftasks”(e.g.remindersandmemoryaids)•Jobaidsdecrease•theamountofdecisionmakingneeded•theneedtomemoriseproceduresandreferences•theneedtocarrymanuals•Practical-designedtobeconsultedonthejobPlugCoverJobAidCordGripBlueorBlackNGreen&YelloworGreenE13AFuseRed22mmFittedWithBS136213AFuseAlwaysFitBS1362ReplacementCartridgeFuse6mm6mm6mmL32mm12mmOrRedBrownIBedWash/KilllineworkforuseduringbedturnaroundK31I12I15I20I1I2I17I3I4K15K3K8R9401I13I16I18I11K30I19I7I8I5I6V9404K1P9403K13K14K20K16WashwaterTank9401K5MFRC-38KillingwaterPIFIPIHotN2N2blowingE94022ndStageproduct1ststageproductV9402finalproduct1ststagefeed2ndstagefeed3rdstagefeedK4Topheaderwash/killlineworkBottomheaderwash/killlinework16Proceduralviolations•WhetheraprocedureislikelytobefollowedornotisasimportantaquestionasconsideringthetechnicalmeritsoftheprocedureEncouragingcompliance•Designthejobsothatthecorrectprocedureishardtoavoid•Basetheprocedureonhowtaskisactuallyperformed*•Identifyincentivestotakeshortcuts•Adoptacontrolandreviewprocess•Writeprocedures:–withtheuserinmind–involvingusers.*AslongasHS&EisnotcompromisedInformationandguidance•HIDinformationsheet•HSG48(especiallypages26-31)•Improvingmaintenanceguide•Improvingcompliancewithsafetyprocedures-toolsHSEapproachExamineprocedure(s)forsafety-criticaloperation(s)Forexample:•Start-up&shut-down•Commissioning•Abnormal/emergency•Bulkloading/unloading•Maintenance•Plant/processchangeProceduresforsafety-criticaloperations•Stateswhodoeswhat,andwhen?•Useofpresenttense&activevoice?•OnlyuseUPPERCASEforemphasis?•Donotusemorethanonenegative?•Oneactionforeachproceduralstep?•Givequantitativevaluesandlimits?•Quantitiesanddimensionscorrespondtothoseoncontrols&displays?QuestionsformanagementDoesthesitehaveprocessesfor:•Determiningwhichsafetycriticaloperations/tasksneedprocedures(e.g.byHAZOP/riskassessment);•Consideringhowtheworkactivitiesofnon-companypersonnel(e.g.contractors)aremanaged;•Approvingoperatingprocedures;•Involvingoperatorsinwritingofprocedures;•Ensuringconsistencyintheproceduresusedacrosssite/plantforidenticaltasksoroperations;Questionsformanagement2•Ensuringthatproceduresremainvalidandup-to-date;•Theremovalofallout-of-dateprocedures;•Ensuringthatstaffaretrainedinnew/updatedprocedures;•Ensuringcompliancewithprocedures;•Reviewingrelevantproceduralcontrolsfollowinganincidentorauditnon-complianceTalktoworkforce•Dotheyusetheprocedures?-Whynot?•Weretheyinvolvedindevelopingthem?•Aretheyup-to-date?•Dotheyreflectreality?•Aretheyoftherightlevelofdetail?•Dotheyincludesafetycriticaltasks?•Aretheyeasytouse?Workforcecontinued•Dooperatorsuse‘blackbooks’?-Why?•Askthemtoexplainhowtodoatask–Dotheyalwaysdoitthatway?–Howdotheyrememberhowtodoit?•Dotheyidentifyallnecessarywarnings?•Whatdotheyreallythinkofprocedures?
优质VIP
