An incident revealed the need to significantly improve existing procedures for several batch processes.This paper describes how a team of operators were trained to revise existing procedures and develop new procedures in a way that would eliminate many error-likely situations.The strategy included (1) identifying the workers' job tasks that required written procedures,(2) ensuring that the procedure steps were written accurately an din the correct sequence by walking through the procedures in the field,(3)clarifying and simplifying procedure steps based on input from an experienced operator unfamiliar with a particular procedure,(4) eliminating gaps and overlaps between various procedures written by different operators,and (5) evaluating the consequences of errors in performance of the procedures.The result of this effort was a much improved set of procedures,a more uniformly trained workforce,and a measurable decline in procedural deviations.As a by-product of this effort,the operators identified many human-machine interface improvements that would simplify the procedures and make them safer.
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