Procedures are agreed safe ways of doing things – consisting of instructions and related information needed to help carry out tasks safely and efficiently. Procedures are not necessarily step-by-step instructions, but can also be checklists, decision aids/tables, diagrams, flow-charts and other types of ‘job aids’.
Why are procedures needed?
- To minimise error/mistakes;
- To ensure critical safety/quality steps are carried out;
- To provide a basis for training;
- To protect against loss of operating knowledge;
- To standardise working practice; and
- To meet statutory requirements.
The provision of information and instruction is a basic requirement of health and safety legislation in many countries, such as the UK Health and Safety at Work etc. Act 1974, which states that:
“General duties of employers to their employees.
Section 2 (2)(c) the provision of such information, instruction, training and supervision as is necessary to ensure, so far as is reasonably practicable, the health and safety at work of his employees”.
Procedures, especially operating and maintenance procedures, are important for the prevention of accidents and ill health. Written procedures are vital in maintaining consistency and in ensuring that everyone has the same basic level of information. They are a key element of a safety management system and an important training tool. However, poor procedures can be a reason for people not following recommended actions.
As well as being technically accurate, procedures need to be well-written, usable and up to date. HSE guidance (Writing procedures) provides the following ‘test yourself’ questions:
- Are your procedures accessible?
- Are they actually followed by staff?
- Are they written so that they can be understood and followed easily?
- Do they reflect the tasks as they are actually carried out?
- Do the procedures include key safety information?
- Are they kept up to date and reviewed occasionally?
Procedures ideally need to:
- be accurate and complete;
- be clear and concise with an appropriate level of detail;
- be current and up to date;
- be supported by training;
- identify any hazards;
- state necessary precautions for hazards;
- use familiar language;
- use consistent terminology;
- reflect how tasks are actually carried out;
- promote ownership by users;
- be in a suitable format; and
- be accessible.
Why do people not always follow procedures?
Non-compliance with rules, procedures and instructions – drawn up for the safe or efficient operation and maintenance of plant or equipment – is a significant cause of industrial accidents. Furthermore, these ‘violations’ are a frequent cause of production losses and unreliable maintenance.
Non-compliances or deviations occur for many reasons and are seldom willful acts of sabotage or vandalism. Most stem from a genuine desire to perform work satisfactorily given the constraints and expectations that exist. Deviations from agreed procedures can become the norm within the organisation.
How do you ensure compliance with procedures?
The exact strategy to reducing non-compliance will depend to a large extent on the reasons why procedures are not followed, for example:
- If not following a rule, procedure or instruction has become the normal way of behaving within the person’s peer group, employees see little value in it and there is insufficient management commitment to enforcing it. Consider explaining the reasons behind the rule; change the rule if it becomes inappropriate or consider rationalising work systems to reduce the numbers of unnecessary rules. If the rule is critical, then increase the probability of detection.
- If a rule is impossible or extremely difficult to work to in a particular situation (e.g. conflicting requirements or physically impossible to perform the activities in the specified manner) then improve job design and the working conditions; implement a suitable reporting system and provide more appropriate supervision.
The following will make it more likely that procedures will be used in practice:
- Ensure that the ‘right’ way to do the job requires less time and effort. Identify incentives to take short-cuts.
- Use the right format of procedure to suit the task and the user (e.g. checklist, flowchart, diagram, decision-aid, charts, photos).
- Involve end-users in the development and implementation of procedures (to help close the gap between ‘work as imagined’ and ‘work as done’).
- Design the task, job, environment, equipment, etc. to support the user in following the procedures. Design the job so that the correct procedure is hard to avoid.
- Balance detail in procedures with the experience and competence of the user.
The role of procedures in a major incident
Lessons from BP Texas City:
- A work environment that encouraged operations personnel to deviate from procedure;
- Acceptance of procedural deviations during past startups, and failure to ensure that the procedures remained up-to-date and accurate;
- Management did not ensure that unit operational problems were corrected over time, leading operators to deviate from established procedures;
- The startup procedure lacked sufficient instructions for the Board Operator to safely and successfully start up the unit.
Key principles in managing procedures
Are procedures appropriate?
First of all, is a procedure the right form of risk control? Administrative controls such as procedures are not as reliable as engineering or hardware/design solutions. They should be used where an engineered control is not possible or reasonably practicable to implement.
Determine which operations or tasks need procedures (not all of them will). You need to be able to demonstrate the process used to make these decisions, so note the criteria that you used. Inform the development of procedures by talking to users and walking through the task with them.
What should they look like?
Understand who the documents are intended for and how will they be used (for training, emergency response, normal operations etc.), as this will inform the type of document and level of detail. Do you need procedures that are referred to step-by-step each time the task is performed; those that may be referred to periodically during the task; or those that are provided for information/training purposes?
For example, checklists may be more appropriate for use on-the-job. The more rarely a procedure is used, (e.g. plant upsets, emergency response), the more detailed the procedure may need to be.
Procedures should be accurate and presented in a format that is compatible with the needs of the end user and suitable for the task that they are designed to support. Procedures should identify the risks and controls involved in completing the task, including human error. What might go wrong – and what do you expect the user to do about this?
Be careful about setting a standard format or template for all company procedures – there’s a danger that a simple fit-for-purpose procedure could become unwieldy if certain sections have to be included. Consider providing a selection of templates that can be adapted by a procedure-writer.
A process for managing procedures
Have a formal mechanism in place to ensure that staff are trained in new/updated procedures – include information on why the procedure was issued, when it is to be used and how it differs from previous procedures.
Create a process to ensure that procedures remain valid and are up-to-date; along with a formal mechanism for the removal of out-of-date procedures. Ensure that relevant procedural controls are reviewed following an incident, audit non-compliance, or as a result of changes in the workplace.
Besides assuring the technical content, consider how the procedure is presented and formatted – most of the guidance on this issue is consistent, and a summary of can be found in the UK HSE procedures audit tool. I have seen many procedures include basic information about PPE, or reference the general site rules. I would suggest that basic site rules should not be included in every procedure – and only document PPE requirements if they are specific to the hazards of the task.
Finally . . .
As well as considering procedures, also address the design of equipment, controls and interfaces to which the procedures refer. There’s no point in having a clear instruction of what to do and when to do it, if for example the equipment to which the procedure refers is not suitably labelled and designed according to human factors principles.
More information on procedures
Writing procedures. Extract from HSE publication Reducing error and influencing behaviour (HSG48, ISBN 978 0 7176 2452 2, Second edition, published 1999). Contains useful information on layout, formatting and style of procedures.
Revitalising Procedures. An information sheet that I produced in 2004 whilst working for the UK HSE. Provides guidance for employers on how to develop procedures that are appropriate, fit-for-purpose, accurate, ‘owned’ by the workforce and, most of all, useful.
Reliability and usability of procedures. Extract from HSE Inspectors Human Factors Toolkit. Useful for checking your own use of procedures.
Human Factors – Procedures and Instructions. This Information Paper, published by NOPSEMA, is designed to foster continuous improvement in the development, implementation and maintenance of procedures and work instructions. It provides information and recommendations on document content, structure and layout, implementation, and modifications. A list of critical success factors for procedures and instructions are also included. National Offshore Petroleum Safety and Environmental Management Authority (2013).
Procedures audit tool. Style, layout and language are important elements of usability. This tool summarises recognised good practice and can be used by employers to actively review and audit these aspects of their own procedures. Published by UK HSE, 2009.