Safety Moment: Following Procedures Can Save Lives

Presented By

Maurice Wilkins - Yokogawa

Conference: Galveston 2015

We come across procedures every day and often take them for granted; in fact we perform familiar procedures by rote, often not remembering having done so. How many times have you driven somewhere and then not remembered the journey? It’s because you are so familiar with the procedure of driving a car that your mind was on other things. The same can happen with process operations.

Although standard operating procedures (SOPs) exist for all process operations, the operators often run the process without using them, or even tweaking them for ‘better’ results. But what happens when things go wrong?

There have been several well publicized offshore, refinery and petrochemical incidents over the past few years. Incident reports show that many of these incidents could be attributed to ‘human error’. This can happen in several ways, such as error of operation, errors due to omission of steps or actions, faulty diagnosis or ‘jumping to the wrong conclusion’, sometimes due to panic under stress.

The aircraft and airline industries have been at the forefront of procedure based operations, after lack of procedures almost canceled the Boeing B-17 Flying Fortress program. A test flight crash occurred due to a gust lock being left open and it was claimed the plane was too complicated to fly. The test pilots developed procedures for all aspects of a flight from pre-flight inspections to take off, landing and taxiing to the terminal. These procedures are followed on all aircraft to this day, whether a private plane or an Airbus A300. In fact it was Capt. Chesley B. “Sully” Sullenberger and crew following procedures that saved US1549 in the Miracle on the Hudson. None of the crew had ever worked together before, but when the bird strike happened they all knew what to do. The International Society for Automation (ISA) formed a committee (ISA106) in 2009, to develop a standard for procedural operations in the continuous process industries, aimed at addressing the development and use of procedures in normal and abnormal situations.

The standard will show when procedures should be automated and when manual procedures will suffice and deal with the development lifecycle of procedures. This presentation will discuss the use of procedures in the aircraft industry, medical industry and compare them with the process industries to see what lessons can be learned to ensure safer operations.

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