Properly Handle Abnormal Situations

Providing effective operating procedures is crucial to success

By Peter T. Bullemer, Human Centered Solutions, LLC

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One of the ASM Consortium's recommended effective practices is to establish a risk-based methodology to classify procedures in terms of usage. The methodology rates procedures based on expected frequency of use, complexity and potential consequences if the procedure isn't followed. Using the risk rating, procedures are classified into three categories:

• Critical — typically low frequency, high complexity and serious consequences;
• Reference — generally moderate frequency, complexity and consequences; and
• Guidelines — usually high frequency, low complexity and minor consequences.

From a usage perspective, the policy should state for each classification level whether the procedure requires:
• Reviewing prior to use;
• Having the full document or a checklist on hand during execution;
• Initialing each step following completion; and
• Signing-off following completion of all steps or group of steps.

Finally, the plant management team must monitor and reinforce compliance with the policy to ensure operations team members adopt the new practice. Changing organizational culture isn't simple — it just won't happen automatically with the reclassification of procedures. However, a more pragmatic approach to the organization's expectations on the use of procedures will ease the task.

2. Lack of effective methods for determining what abnormal situations procedures should address.
This inherently is about understanding the risks associated with failing to execute a procedure as written and what situations might arise that might make executing the procedure no longer appropriate. Consequently, addressing the challenge requires the use of a risk assessment methodology.

The ASM Consortium's recommended practices [3] use such methodologies to:

• Establish risk-based criteria for procedural use classification (Guideline 1.5); and
• Conduct a procedure-focused process hazard analysis (PHA) as part of critical review (Guideline 1.7).

We've already discussed the role consequence plays in classifying procedures. Clearly, this requires some type of assessment of potential hazards associated with the failure to execute the procedure. Sites that have done this assessment use their usual PHA or Hazard and Operability (HAZOP) methodology. The classification results can be used to identify the specific procedures that require a procedure-focused PHA to determine the content appropriate for execution during abnormal situations, i.e., per the second guideline (Guideline 1.7).

Evaluating the risk associated with the process and operator actions during procedures can identify ways to manage and control hazards that might result from failures in execution. In performing this activity, the procedure developer must be knowledgeable about past PHA findings and aware of specific engineering controls that improper execution of the procedure might impact. Furthermore, because the original PHA findings might not have considered the procedures in the analysis of risk, the procedure developer must pinpoint risk specifically associated with procedure execution failure.

The strategy of using risk-based assessment methods for procedure development isn't a new concept to the ASM Consortium members. However, using a risk-based methodology specifically to address the procedural execution failures associated with abnormal situations is a new emphasis evolving out of the recent incident analysis study.

These best practice guidelines represent a starting point. However, a gap still seems to exist in addressing the challenge associated with the procedure development strategy for determining what abnormal situation or condition might arise that impacts continuation of the procedure.

So, to get a more comprehensive grasp of sources of risk associated with execution failures under abnormal situation management, consider:

• Failure to detect abnormal condition;
• Failure to detect abnormal situation;
• Lack of understanding of impact;
• Lack of awareness of hazard; and
• Inappropriate response to abnormal situation.

In addition, to better consider the implications of an abnormal situation, when examining potential safeguards the reviewers should determine whether an action or actions would allow the procedure to continue or whether it should be aborted.

3. Insufficient metrics for understanding the causes of procedural failures. This implies a need to enhance incident reporting to provide better information on the weaknesses of the procedure management system. Any solution must address both metric definitions and metric reporting.

Metric definitions should include both lagging and leading indicators. For instance, establish a set of lagging indicators that addresses failures in procedure scope, content or design that stymie procedure execution in abnormal situations. Likewise, create a set of leading indicators that identify failures in management system elements.

Leading indicator metrics should measure whether or not operations teams understand the plant policy on procedure use and whether personnel comply with the policy. These metrics can help address the challenges associated with "Procedure Not Used."

Incorporate the new lagging metrics into a common site reporting system that addresses all process safety incidents and promotes accurate and comprehensive reporting.

Moreover, build the leading metrics into a common site reporting system that encourages accurate and periodic reporting — e.g., use the behavioral safety protocol for process safety management interventions on procedures — not just behavioral safety (assessment, feedback and recommendations for improving; and necessary number of observations per month). This may require adapting the protocol to align with metric needs. Validate the effectiveness of the metrics in terms of reductions in the number of procedure-related incidents (per lagging indicators) as well as procedural deviation observations.

It's also crucial to establish an effective method for analyzing leading and lagging metrics over time to determine systemic failures in procedure development practices.

This suggested strategic approach to a more-comprehensive metrics-based solution for understanding the nature of procedure execution failures associated with abnormal situations requires effort to define procedure-related leading and lagging indicators and enhance the common site incident reporting system.

In general, the ASM Consortium analysis reinforces the value of establishing an effective procedure management system for the development, deployment, and maintenance of procedure work instructions. The outlined approach to the analysis of incident reports can provide any organization with a good understanding of the specific ways to improve the procedural management system for better operations performance.


PETER T. BULLEMER is senior partner at Human Centered Solutions, LLC, Independence, MN. E-mail him at

1. Bullemer, P.T., Kiff, L. and Tharanathan, A., "Common Procedural Execution Failure Modes During Abnormal Situations," J. of Loss Prevent. in Proc. Ind., pp. 814–818, 24 (6), 2011.
2. Bullemer, P.T. and Laberge, J.C., "Common Operations Failure Modes in the Process Industries," J. of Loss Prevent. in Proc. Ind., pp. 928–935, 23 (6), 2010.
3. Bullemer, P. T., Hajdukiewicz, J. and Burns, C., "Effective Procedural Practices: ASM Consortium Guidelines," Abnormal Situation Management Consortium, Minneapolis, MN, 2010.



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