OPERA Optimising Procedures for Efficiency and Reduced Accidents A systematic Approach to writing better procedures by involving the workforce Dr David.

OPERAOPERAOOptimising ptimising PProcedures for rocedures for EEfficiency fficiency

and and RReduced educed AAccidentsccidents

A systematic Approach to writing better A systematic Approach to writing better procedures by involving the workforceprocedures by involving the workforce

Dr David EmbreyDr David EmbreyManaging DirectorManaging Director

Human Reliability AssociatesHuman Reliability Associates

www.humanreliability.comwww.humanreliability.com

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Some common assumptions about Some common assumptions about proceduresprocedures

‘Fully documented step by step ‘Fully documented step by step

procedures need to be actively referred procedures need to be actively referred to when all tasks are carried out’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 You cannot write procedures for everything’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

Three Phases of OPERAThree Phases of OPERA

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

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

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

Based on preferred working practices

Developed by consensus

processBest PracticeBest Practice

Control hazards identified in risk

analysis

Reviewed by• Safety• Quality• Technical

Specialists

CriticalityScreening

GenerateTask

Inventory

DocumentCurrentPractice

AgreeBest

Practice

DocumentBest

Practice

OperatorInput

TaskAnalysis

Tools

Formattingguidelines

ReferenceProcedure

Stages

Inputs

Consensus Group

(inc TechnicalInput)

Task step hazard analysis

Risks

Phase 1: Develop Best PracticePhase 1: Develop Best PracticeTraining needsCompetence assessment Level of support

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Black books are a useful source of Black books are a useful source of informal, undocumented knowledgeinformal, undocumented knowledge

How the Consensus Process WorksHow the Consensus Process Works

Technical experts

I see a problem

Facilitator(System user peer group)

Technical questions

Proposed best practiceConsensus

group

Best Practice

Agreed by all

Job aids

Training specification

DifferencesPracticalrealities

Facilitators talk to all systemusers whodescribe

current practice

Risks controlled

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Task Experts People who do the job

Facilitator collects information and

develops provisional best practice

Reviewed by each shift & modified if necessary

Task analysis information

Potential hazards /

consequences Training issues

Hazard Add.

Info.

Generic skills

Specific knowledge

Level of support

Reference Procedure formatReference Procedure format

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Maintaining Best PracticeMaintaining 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?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

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5%20%

75%

Step by stepprocedures

Supported byjob aids

No writtenprocedures

How often are written procedures How often are written procedures actuallyactually needed ‘in hand’ when a needed ‘in hand’ when a

task is performed?task is performed?

The MatrixThe Matrix for determining for determining appropriate level of supportappropriate level of support

Step by Step instruction required (SBS)

Low

Low

Medium

High

NWI

NWI

NWI NWI NWI

NWINWI

NWI JA

NWI

NWI JA

NWI

JA

JA

SBSNWI

NWI NWI SBS

NWI JA

JA

JA

NWI

JA SBS

Medium High

Freq Infreq Rare Freq Infreq Rare Freq Infreq Rare

Task Criticality

Task Familiarity

Ta

sk

Co

mp

lexi

ty

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Job Aid required e.g. checklist/memory aid (JA)

No Written Instruction required (NWI)

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Examples of Job Aid Examples of Job Aid FormatsFormats

• Step-by-step lists

• Posters

• Flow charts

• Labels

• Simplified drawings

• Decision tables

• Check list sheets

• Step-by-step lists

• Posters

• Flow charts

• Labels

• Simplified drawings

• Decision tables

• Check list sheets

Cord Grip

Blueor

Black

N

Green &Yellow

orGreen

E 13A

Fus eBrownor

Red32

mm

12m

m

22 mm

Fitt

ed W

ithB

S 1

362

13A

Fus

e A

lway

sF

it B

S 1

362

Rep

lace

men

tC

artr

idge

Fus

e

6mm

6mm

6mmLL

UK Plug Cover Job AidUK Plug Cover Job Aid

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Furnace /Hot Oil - Label Furnace /Hot Oil - Label

• Maintain burner pressure above 0.6 bar

• Keep oil temperature 170 - 225C

Flue gas O2

Very unsafe. Do not increase air

Unsafe. Increase air gradually

EmissionsIncrease air

Target range

Wasted fuel

1%

2%

5%

6%

Furnace Trip Job AidFurnace Trip Job Aid

How longis furnace likely to

be down?

Furnace Trip Reset Alarms

Identify initiator event

Temporary unit shut

down

Column temperature and reflux to manual

Reduce feed

Stop hot oil to columns 5 and 7

Bypass column 6 steam raisers

Reduce column reflux rates

Maintain column levels

Stop tank 7 and 8 import

Rundown to off grade

Stop overhead pumps as condenser levels fall

More than 1 hour

Commence furnace start-up procedure

Reset 98-DEA-80

Light pilot flame

Return Unit to normal

Did pilotflame light?

Attempt to re-light furnace

Yes

Yes

Is hotoil temperature

above150°C?

No

Less than 1 hour

No

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Planning Job AidsPlanning Job Aids

Base final decision on what Base final decision on what users want and need - listen users want and need - listen to feedback!to feedback!

1

2

3

Low

Low

Medium

High

NWI

NWI

NWI NWI NWI

NWINWI

NWI JA

NWI

NWI JA

NWI

JA

JA

SBSNWI

NWI NWI SBS

NWI JA

JA

JA

NWI

JA SBS

Medium High

Freq Infreq Rare Freq Infreq Rare Freq Infreq Rare

Criticality

Familiarity

Com

plex

ity

Base initially on Base initially on decision aid tabledecision aid table

Get all the Get all the potential users potential users

togethertogether

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Case Study Case Study Improving Procedures Compliance at Improving Procedures Compliance at a Major Multinational Chemical Sitea 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 Case Study Improving Procedures Compliance at a Major Compliance at a Major MultinationalMultinational

Chemical SiteChemical 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)

34%Resent being told how to do job

44%Too time consuming

19%Experienced people don’t need them

47%Too restrictive

62%Too long if followed to the letter

Find a better way of doing them

72%Instead rely on skills & experience

42%More difficult to do work

40%Don’t understand why they are necessary

% agreeProcedures are not used because…

70%Assume have knowledge

37%No policy on when should be used

42%

Most procedures manuals Most procedures manuals were rarely accessedwere rarely accessed

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+52% Don't understand why they are necessary

+18%Not aware they exist

+17%Identification difficult

+21%Too complex

+19%Not best practice

 +52%Unworkable

Improvement over 3 year period

Opinions: Procedures are…

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

Statistically significant changes

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Case Study ConcludedCase Study ConcludedWas the process successful?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 ConcludedCase Study ConcludedWas the process successful?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 Summary of Recommended StrategyStrategy

• 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

Real Men Don’t Use Procedures!Real Men Don’t Use Procedures!

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