OPERA Optimising Procedures for Efficiency and Reduced Accidents A systematic Approach to writing better procedures by involving the workforce Dr David Embrey Managing Director Human Reliability Associates www.humanreliability.com

Some common assumptions about procedures ‘Fully documented step by step procedures need to be actively referred to when all tasks are carried out’ – The type and level of detail depends on the level of expertise for the specific operators and tasks concerned – Familiar, simple tasks usually do not require written procedures at the point of use – The Matrix provides guidelines for the appropriate form of procedural support » Risk, complexity, frequency of task performance

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‘You cannot write procedures for everything’

• For routine situations OPERA allows best practices can be defined and documented as the most cost effective way(s) of carrying out the task • For abnormal situations, job aids must be provided for dealing with situations that can be anticipated • For high risk, unpredictable situations, need to define generic procedures to get the system to a safe state and buy time

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Three Phases of OPERA

Develop Best Practice

– Participation not consultation – Reach consensus – Make Preferred Practice = Best Practice

Support Best Practice

– Balance between job aids and procedures – Training & assessment linked to Best Practice

Maintain Best Practice

– Maintain an open culture – Use feedback to update Best Practice

Developed by consensus process

Control hazards identified in risk analysis

Best Practice

Reviewed by • Safety • Quality • Technical Specialists

Based on preferred working practices

Tools Criticality Screening

Phase 1: Develop Best Practice

Task Analysis

Task step hazard analysis

Formatting guidelines

Training needs Competence assessment Level of support

Reference Procedure

Generate Task Inventory

Stages

Document Current Practice

Inputs

Operator Input Agree Best Practice Consensus Group (inc Technical Input) Document Best Practice Risks

Black books are a useful source of informal, undocumented knowledge

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How the Consensus Process Works Practical realities Facilitators talk to all system users who describe current practice Differences

Task Experts People who do the job Facilitator

(System user peer group)

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Training specification

Consensus group

Technical questions Proposed best practice

I see a problem

Best Practice Agreed by all

Job aids Technical experts Risks controlled

Facilitator collects information and develops provisional best practice

Reviewed by each shift & modified if necessary

Reference Procedure format

Task analysis information Potential hazards / consequences Hazard Add.

Info

.

Training issues Generic skills Specific knowledge Level of support

Maintaining Best Practice

• Encourage and use feedback from users • Maintain channels of communication with the sharp end via facilitator • Reapply OPERA to generate new practices and supporting job aids & refresher training: – plant/equipment changes – changes in working practices – operational experience – regulatory change

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What are Job Aids?

“Any source of information used to support the successful performance of tasks” (e.g reminders and memory aids) Intended to complement but not replace skill 12

How often are written procedures actually needed ‘in hand’ when a task is performed?

5% 20% Step by step procedures Supported by job aids No written procedures 75% 13

The Matrix for determining appropriate level of support

Task Criticality Task Familiarity Low Medium High Low Medium High Freq Infreq Rare Freq Infreq Rare Freq Infreq Rare NWI NWI NWI NWI NWI NWI NWI NWI NWI NWI NWI NWI JA NWI JA JA JA SBS NWI NWI NWI JA JA JA JA SBS SBS No Written Instruction required (NWI) Job Aid required e.g. checklist/memory aid (JA) Step by Step instruction required (SBS)

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Examples of Job Aid Formats

• Step-by-step lists • Posters • Flow charts • Labels • Simplified drawings • Decision tables • Check list sheets

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UK Plug Cover Job Aid

N

Blue or Black Green & Yellow or Green

E

22

L

6mm Brown Red Cord Grip

13A

Furnace /Hot Oil - Label

Flue gas O2 6% 5% 2% 1% Wasted fuel Target range Emissions Increase air Unsafe. Increase air

gradually

Very unsafe.

Do not

increase air • Maintain burner pressure above 0.6 bar • Keep oil temperature 170 - 225C

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Furnace Trip Attempt to re-light furnace Reset Alarms Identify initiator event How long is furnace likely to be down?

More than 1 hour Less than 1 hour Temporary unit shut down

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Commence furnace start-up procedure Reset 98-DEA-80 Reduce feed Stop hot oil to columns 5 and 7 Column temperature and reflux to manual Bypass column 6 steam raisers Light pilot flame Did pilot flame light?

Yes Return Unit to normal No Yes Stop tank 7 and 8 import Rundown to off grade Is hot oil temperature above 150 °C?

No Maintain column levels Reduce column reflux rates Stop overhead pumps as condenser levels fall Furnace Trip Job Aid

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Planning Job Aids

Base initially on decision aid table Criticality Low Medium High Familiarity Freq Infreq Rare Freq Infreq Rare Freq Infreq Rare Low NWI NWI NWI NWI NWI JA NWI NWI JA Medium NWI NWI NWI NWI NWI JA NWI JA SBS High NWI NWI JA NWI JA SBS JA JA SBS Get all the potential users together Base final decision on what users want and need - listen to feedback!

Case Study Improving Procedures Compliance at a Major Multinational Chemical Site

• Failure to manage flare line incident almost led to a catastrophic failure • Analysis of incident showed that main cause was failure to comply with procedures (HSE investigation) • HRA asked to investigate and propose solutions across site (~1000 employees)

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Case Study Improving Procedures Compliance at a Major Multinational Chemical Site • Phase 1: Procedures culture survey developed and applied across site • Phase 2: Procedures culture change process OPERA ( Optimising Procedures for Efficiency and Reduced Accidents ) developed and piloted across site • Phase 3: OPERA rolled out across all production units on site over 4 year period (Owned by workforce, facilitated by HRA)

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Procedures are not used because…

Don’t understand why they are necessary More difficult to do work Instead rely on skills & experience Find a better way of doing them Too long if followed to the letter Too restrictive Experienced people don’t need them Too time consuming Resent being told how to do job No policy on when should be used Assume have knowledge

% agree 40% 42% 72% 42% 62% 47% 19% 44% 34% 37% 70%

Most procedures manuals were rarely accessed

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Results of applying OPERA over a 3 year period Changes in opinions of workforce

Opinions: Procedures are… Improvement over 3 year period

Unworkable Not best practice

+52% +19%

Too complex Identification difficult Not aware they exist Don't understand why they are necessary Statistically significant changes

+21% +17% +18% +52%

Case Study Concluded Was the process successful?

• Plant start-up time substantially reduced, giving ~500,000 pounds saving in first year • Many cost reductions due to reduced time needed to conduct yearly start-ups/shutdowns • Generally procedures followed as documented

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Case Study Concluded Was the process successful?

• Reduced effluent emissions • Improved safety record • After 5 years savings of ~3 Million pounds produced • Site now has the highest production levels per employee of any site worldwide (Formerly bottom of the international league table)

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Summary of Recommended Strategy

• Start with the most critical tasks (from Task Inventory & Criticality analysis) – May use existing procedures as starting point but need to verify against actual working practices • Develop Reference Procedures for the Critical Tasks (depending on resources) • Develop Job aids, training and competency specifications to control risks • Proceed to other tasks as resources become available

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Real Men Don’t Use Procedures!

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