The Abnormal Situation Management® Consortium funded a study to investigate common failure modes and root causes associated with operations practices. The study team analyzed 20 public and 12 private incidents for common operations practice failure modes including the BP Texas City Incident. A key finding from the analysis was that ineffective first line supervision was the 2nd most frequent operations practice failure (65 out of 539 observed operations practice failures), representing 12% of all failures. An examination of the common manifestations of the supervision common failure mode identified a list of potential proactive indicators of weaknesses in operations supervision practices. An operations audit checklist is presented to enable plant personnel to assess their potential vulnerability to this common failure mode.
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