Temporary Instrumentation and Controls Bypass - Need / Call to Action | AIChE

Temporary Instrumentation and Controls Bypass - Need / Call to Action

Last updated September 27, 2018 | Element: Need / Call to Action

Incidents Continue to Happen

Examples to be published soon.

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is Healthy – Just because it has not happened yet (or here) does not mean it will not happen in the future!

  • Is a sense of vulnerability a critical part of the mindset of every employee and contractor?
  • Do you require consistency in practice from everyone in the organization?
  • Do you have systems in place to determine if inconsistencies exist?
  • Do people believe that “yes, it can happen here”?
  • Do people believe that “yes, we have similar vulnerabilities”?
  • Have you experienced similar incidents but without consequences (i.e., near misses)?
  • Do you combat organizational overconfidence that can be stimulated by past good performance?
  • Do discussions on potential vulnerabilities take place between operations and senior leadership?

Prevent Normalization of Deviation

Normalization of deviation is defined as… 



“The gradual process through which unacceptable practice or standards become acceptable.   As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization."

                                                                                                   Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)

“A gradual erosion of standards of performance as a result of increased tolerance of nonconformance"

                                                                                                                                                                                                 CCPS Glossary 

Signs of Normalization of Deviations – Does this describe your organization?

  • If a deviation is absolutely necessary, are there defined steps that must be taken (i.e., a written variance procedure)?
  • Do these defined steps (or variance procedure) require a detailed risk assessment and approval from multiple levels within the organization?
  • Are the expectations clear that no one individual alone is permitted to determine whether a deviation is permissible?
  • Do you allow operations outside established safe operating limits without a detailed risk assessment?
  • Are willful, conscious, violations of established procedures tolerated without investiga-tion or without consequences for the persons involved?
  • Can employees be counted on to strictly adhere to safety policies and practices when supervision is not around to monitor compliance?
  • Are you tolerating practices, or conditions that would have been deemed unacceptable a year or two ago?  For example:
    • Do you allow routine bypasses during plant start-up without additional means of managing risk?
  • Are all employees empowered to stop work for any situation deemed unsafe?

Evaluate Your Program

Do you audit your Safeguard Bypass program to ensure the program is yielding the intended results?

Do you review the following items:

• Written Bypass procedures?

• Bypass permits or temporary MOCs?

• Roles and responsibilities of persons involved in Bypass activities?

• Training and competency of persons involved in Bypass activities?

• Compensating measures that should be in place before Bypass activities are conducted?

• Job observations performed on Bypass activities?

Have you evaluated your Bypass audit program?

  • To ensure the quality of the audit process (i.e., protocols, sampling strategies, etc.)?
  • To ensure the competency levels of the auditors?
  • Does your Bypass procedure reflect the desired intent and is this intent adequately de-tailed in procedural instruction?
    • Is the “goal” of your program to complete the permit or to use the permit as a tool to facilitate the execution of safe work?
  • Does the execution of the procedure yield the intended results?  Are you evaluating your program for:
    • Procedural Compliance – are actions and tasks in compliance with procedural requirements?  (Paper Control), and
    • Program Health – is your system providing the intended results?  (Actual Execu-tion)                                                                                                                    
  • Do you know of any site or company incidents related to Bypassing?
    • Have you discussed the results and causes within your organization?
  • Do you know of any site or company near misses related to Bypassing?
    • Have you discussed the results and causes within your organization?

Continually Improve Your Program

Are you considering improvements to prevent future incidents?  Here are some ideas you may want to consider:

• How frequently do you review CSB, Process Safety Beacon and other relevant incident communication having learning potential with all members of the organization?

• Do you track specific bypass-related metrics that can be used to determine program ef-fectiveness and improve performance?

• Have you benchmarked your program against other programs in your industry?

• How often do your senior managers visit the field to inspect bypass status?

• Do you have a requirement to periodically update your program?

• Do your workers (those closest to the work), have an easy method to suggest improvements to your program?