Procedures as a productivity and safety tool

Jean-Yves Fiset, Eng., Ph. D.jyfiset@shumac.qc.ca

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Outline

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• Why bother?

• What is in a procedure

• What procedures can do for you

• Issues and tips

• A case study: abnormal situation management

• Resources

Why Bother?

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In Preliminary Findings, CSB Investigators Report Bayer CropScience Explosion Was Caused by Runaway Chemical Reaction; Cite Significant Lapses in Process Safety, Outdated Operating Procedures

http://www.csb.gov/newsroom/detail.aspx?nid=238&SID=0&pg=3%2f%2f%2f%2f'%2c%2f%2f%2f'%2c%2f%2f'%2c%2f'%2c'%2c&print=y

Human Performance Analysis of Industrial Radiography Radiation Exposure Events http://www.osti.gov/bridge/servlets/purl/147724-h3ucf2/webviewable/147724.pdf

What is in a Procedure

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• « A set of instructions to assist specified users in carrying out specified task in a specified context of use to achieve specified results »

ChecklistsOperating manuals« Cardex »ProceduresProtocols

Usually include•Pre- or entry conditions•Steps•Actions, decisions….•Specification of order of execution for none, some or all of the steps•Warnings and cautions•Post-conditions•« Configuration management »

What procedures can do for you

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• For the individual – Support decision-making in stressful situations– Prevent or mitigate memory lapses– Document what was done

• For the organization– Train new staff – Refresh experienced staff on infrequent tasks– Support continuity planning– Manage events

Frequent Issues

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• Using them

• Producing them

• Complying with them

CAP 716 AVIATION MAINTENANCE HUMAN FACTORS

Tips

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• Strategy: define– Purpose of the procedures

• Help the organization achieve its purpose OR satisfy some external body OR both OR…

– Compliance policy (including how to handle deviations)

• E.g., Procedures shall be used as written and no deviation shall be tolerated… OR…. Procedures as guides… OR…several classes…

– How compliance will be assessed– How the procedures will be maintained

Tips

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• Writing good procedures is tough but gets easier with a bit of practice– Experts at

the job are not necessarily great procedure writers

IOWA DEPARTMENT OF PUBLIC HEALTH - INDUSTRIAL RADIOGRAPHYEXPOSURE DEVICES REGULATORY GUIDEhttp://www.idph.state.ia.us/eh/common/pdf/radiological_health/industrialrad99.PDF

Common mistake

Tips

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• Tactics– Specify for whom you write (or review) procedures and the

purpose of the procedure– Differentiate between « conceptual » and « procedural »

information AND organize both adequately– The process is: analyze the needs and constraints, produce

a first version, assess, and correct => repeat as required => then deploy and train

– Writer’s guide• Process for authoring, reviewing and authorizing• Authorized words• Fonts, styles, headings• Syntax• Principles and rules• Templates for pages and for procedures

Tips

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• Ensure the text is legible– For text, avoid color like

the plague– Typically, you should

specify font size and « type » (e.g., Times Roman). Actual size depends on:

• Distance of use• Environment of use• Characteristics of users

(e.g., age…)• To be safe, may want to

specify larger sizes

Adapted from: http://www.visualexpert.com/Resources/olderdrivers.html,

20 years old 60 years old 75 years old

Sizes should be calculated and

measured on paper – avoid relying on

« points »

Tips

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• Writing individual steps– Keep individual steps simple

• In general: short words in short sentences work best• One instruction by step

– Break down complex steps into simpler, successive steps

– Avoid negative in conditionals like a major plague• Try it:

– IF pressure in Tank 23 is NOT greater than 145 KPa, THEN Observe

– Use right format• steps for instructions, warnings for warnings, and notes for

notes!– Warnings before a step, not after….

– Check boxes or room for initials if each step is to be confirmed

Tips

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• Use the right vocabulary– Always the same word for the same thing

• Few words => fewer mistakes• Words familiar to the staff AND correct for the task• Short words => easier and faster to read• Standardized rules for abreviations

– Use same abreviations throughout

Tips

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– Rules for numbers • Usually, numeral for physical measures and for 11

items or more• Use separations = 277 733 rather than 2877733• Same form• Only the precision required and available• Include units of measure, where applicable• Avoid calculations like the plague

– If absolutely required, provide a calculation aid and enforce its use

• Use ranges => 17 – 23 C rather than 20 ± 3 C

Tips

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• Level of detail– Making the procedure overly detailed does not

help any– Revisions often tend to increase the thickness of

the procedure while decreasing its usefulness…

Training

Level of Detail

For the Procedure

Familiarity

Tips

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• Use good syntax– Active form rather than passive– Avoid inversions

• Longer to read• Higher error rate

– In a step, force sequences only when absolutely necessary

1. Do……2. Do….3. Do….

Sequence forced: ordered list

• Do……• Do….• Do….

a) Do……b) Do….c) Do….

Sequence not forced: unordered list

Common mistake

Tips

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• Putting it all together– Review and

critique– Identify

improvements• Beware of

limits of knowledge on application

Warning?

Tips

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• Some unanswered questions– Pictures? No pictures?– Prose or flowcharts?– Enough, too much, not enough information?

• Solution: combine training and procedure content, and take into account user knowledge before specifying the level of details

– Standards• Some process / attribute standards exist for

some types of user documentation

Tips

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• A few cheap tricks…– The value of pre-testing…

• People will often spend more time explaining why they don’t think it is necessary to validate, walkdown or otherwise test the procedure than it would take to actually do it…

• Testing or validating a procedure solely by talking about it around a table is a weak method

– You will not get it right the first time• If you do, send your résumé…

– Procedures need to be maintained – A desktop review based on the rules and

principles presented here will reveal lots• Compliance with writer’s guide or good practices• Eliminating words without loosing the meaning• Procedural vs conceptual knowledge• ...

Common mystery

Case Study

• Abnormal Situation Management (ASM)

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Case Study

• ASM

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Case Study

• ASM: a procedure-driven approach

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Resources

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• Wieringa, D., Moore, C., Barnes, V., PROCEDURE WRITING: PRINCIPLES AND PRACTICES, 1998. 2nd ed. Columbus, OH: Battelle Press. [ISBN 1-57477-052-7. 243 pages, including index

• For the ASM case study: White Paper - Human Performance and Abnormal Situation Management– Paper copies are available– Can be downloaded from

• www.shumac.qc.ca or • www.shumac.com.ar

Conclusion

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• Procedures are more than « words on paper »• They are not a necessary evil…

– they will help us to …. prevent a situation… respond to a situation… train staff… document our work…

• One of the most cost-effective way to improve operations and safety

• And, best of all, they can be developed and used by mere mortals

Procedures in an Organization

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• The 4 Ps of Safety Management– Management Philosophy– Specifying how safety will be achieved

through People– What management wants people to do

(Procedures) to execute the policy– Practice - What really happens on the job

Adapted from: TP 13739 E Introduction to Safety Management Systems, Transport Canada