(153c) Operational Discipline Is Not Follow the Procedure

When identifying tenets that companies with great process safety performance will possess, the Center for Chemical Process Safety (CCPS) described Operational Discipline as "the second most important aspect of process safety culture" (the first being personal involvement by executives). CCPS then defined the emphasis of Operational Discipline as following procedures; "the performance of all tasks correctly every time."

This emphasis on what is colloquially described as 'always follow the procedure' has been evident in presentations by companies at GCPS and the U.K. IChemE Symposium Series.

Work-As-Done Versus Work-As-Imagined

A procedure-adherence-focused definition of Operational Discipline works well for a subset of situations; when both 1) operational conditions have been anticipated and procedures written, and 2) the written procedures, i.e., Work-As-Imagined, match the task requirements and thus correspond to Work-As-Done.

Procedures are usually under-specified. Procedures, standards, regulations, etc., lack the detail and richness of actual work. And the more specified the prescribed work, the more incorrect is it likely to become in messy real-life work situations:

• Even if work is prescribed in one way, it can and will probably be done in other ways, even if we just consider small differences in implementation.
• Work often incorporates task switching. This meta-level of work is hard or impossible to capture in prescribed work.
• The circumstances of work cannot all be foreseen, let alone guaranteed. The assumed system conditions—staffing levels, competency, equipment, procedures, time—are often more optimal than in practice.
• It is not possible to articulate in a linear written form the precise way that work is done within an interacting system, and it becomes incompatible with real efficiency targets, and insufficient to control abnormal situations.

Conduct of Operations and Teamwork

When Operational Discipline is defined as 'Always follow the procedure' and 'perform the task correctly' it focuses attention on individual behavior. Outcome bias can be used to assign hero versus failure. The seeds of outcome bias are embedded in the Vision 20/20 definition of Operational discipline; "the performance of all tasks correctly every time." The term "correctly" can be judged after the fact, based on the outcome. Hindsight bias can be used to place blame. Leadership can fall from enablement to enforcement. Discipline can come to mean "a punishment inflicted to correct disobedience, poor behavior, or poor performance." Operational Discipline becomes Discipline of Operators.

But Discipline also means "an activity or experience executed to a prescribed set of principles, relationships, authorities, procedures, codes, and/or regulations." This is the discipline of a successful team that understands how to collaborate. This is the discipline embedded in the team concept of Conduct of Operations.

When Procedures Don't Exist: Abnormal Operation and Resilience

When abnormal, unanticipated, or inaccurately specified operational situations arise, 'always follow the procedure' fails as a guideline. By definition, these situations are not, and perhaps cannot be, automated or proceduralized. Abnormal Operations are the initiating event type for the majority of incidents. If Operational Discipline is "the second most important aspect of process safety culture," and if it is limited to 'always follow the procedure,' it does not help in the majority of process safety incidents that are not or cannot be proceduralized.

In these abnormal situations, the team definition of Operational Disciplineis required; a definition that explicitly includes Operational Coordination and that anticipates the need for troubleshooting. This definition of Operational Discipline includes a collaborative and disciplined approach during times when procedures do not exist or are incorrect. CCPS has provided a more robust definition of Operational Discipline that includes the following:

Operational Discipline (OD) is the execution of the Conduct of Operations system by individuals within the organization.

Individuals

1. recognize unanticipated situations,
2. keep (or put) the process in a safe configuration, and
3. seek involvement of wider expertise to ensure personal and process safety.

Conduct of operations (COO) is the embodiment of an organization’s values and principles in management systems that are developed, implemented, and maintained to

1. structure operational tasks in a manner consistent with the organization’s risk tolerance,
2. ensure that every task is performed deliberately and correctly, and
3. minimize variations in performance.

Conduct of Operations

• is the management systems aspect of COO/OD.
• sets up organizational methods and systems that will be used to influence individual behavior and improve process safety.
• results in specifying how tasks (operational, maintenance, engineering, etc.) should be performed.

A good COO system visibly demonstrates the organization’s commitment to process safety.

Operational Discipline in this COO context is a framework that guides how an operations team responds to the requirements of the process and the facility, e.g., in team conduct of operation guidelines and when determining and acting on limiting conditions for operations. When abnormal, unanticipated, or inaccurately specified operational situations arise, this Operational Discipline framework is the basis for safeguarding by the Operations team as they respond through Resilience.

Bibliography

Center for Chemical Process Safety, "A Call to Action Next Steps for Vision 20/20," in 10th Global Congress on Process Safety, New Orleans, LA, 2014.

Center for Chemical Process Safety, Conduct of Operations and Operational Discipline for Improving Process Safety in Industry, 2011, pp. 6-7, Section 5.6.3

Hollnagel, "Can We Ever Imagine How Work Is Done?," Hindsight , Summer 2017, pp. 10-13.

Shorrock, "The Varieties of Human Work," [Online].

Shorrock, "If It Weren't For The People...," Hindsight, Winter 2014, pp. 60-62.

Forest, "Don't Walk the Line — Dance it!," in 14th Global Congress on Process Safety, Orlando, 2018.

Snyder, "Leadership in Catastrophic Incident Prevention: Using Organizational Data to Assess and Respond to High Reliability Loss Prevention Precursors," in 13th Global Congress on Process Safety, San Antonio, 2017.

Cowley and D. Denyer, "The Safety Leadership Paradox," in 12th Global Congress on Process Safety, Houston, 2016.