Achieve zero execution errors through procedure clarity

摘要

It is well-documented that many unplanned manufacturing events could have been prevented if procedures were executed properly.Ensuing investigations cite"failure to follow procedure"as the event root cause,resulting in next step recommendations that include additional operator training and discipline.However,a more systemic failure could be at the root of these unplanned events.When an operational execution error occurs during a process or equipment startup,shutdown,changeover,process loss out of primary containment or other event,how often is"procedure clarity"considered the root cause? This can be considered a major source of error that is overlooked by the industry.Operating procedures originate during capital project installation and are developed using the technical process design basis.Procedures include safety warnings,specific instructions and details required to complete the desired outcome.Following a project startup,the initial operating procedures are red-lined,updated and institutionalized as part of the site's management of change(MOC) process.