Operator Error or Management Failure? Management’s Role in Maintaining Operator Discipline
Abstract
CCPS defines Operational Discipline as “the execution of operational and management tasks in a deliberate and structured manner.” Put more succinctly, operational discipline can be defined as doing the right thing when no one is looking. While Operational Discipline applies to facility personnel across the board, this paper focuses on operator discipline, which this author defines as the requirement to explicitly follow written procedures. The only exception would be if the operator believes that doing so would create harm, in which case the operator should stop all work and only deviate from the procedure with expressed approval from his superiors. This deviation should be processed through the management of change procedures. Failure to follow procedures has caused incidents and near misses throughout the processing industries. It may be tempting to classify these failures as “operator error” and then reprimand the operator. While this may address the symptom, it most likely would not get to the root of the problem. In order to eliminate these failures, it is important to understand and correct underlying causes. For example, are the procedures accurate and clear? Do the operators have the tools and training necessary to carry out the procedure as specified? Has failure to follow procedures occurred previously and, if so, were actions taken by management in response? This paper presents a case history of an industrial accident – a refinery hydrocracker explosion – to illustrate how management failure had led to a failure to follow procedures.
Description
PresentationSubject
Operational DisciplineCollections
Citation
Rothschild, Marc J. (2019). Operator Error or Management Failure? Management’s Role in Maintaining Operator Discipline. Mary Kay O'Connor Process Safety Center; Texas &M University. Libraries. Available electronically from https : / /hdl .handle .net /1969 .1 /193417.