OPERA Optimising Procedures for Efficiency and Reduced Accidents A systematic Approach to writing better procedures by involving the workforce Dr David Embrey Managing Director Human Reliability Associates www.humanreliability.com

1
OPERAOptimising Procedures for Efficiency and
Reduced AccidentsA systematic Approach to
writing better procedures by involving the
workforce Dr David EmbreyManaging
DirectorHuman Reliability Associateswww.humanre
liability.com
2
Some common assumptions about procedures Fully
documented step by step procedures need to be
actively referred to when all tasks are carried
out

• The type and level of detail depends on the level
  of expertise for the specific operators and tasks
  concerned
• Familiar, simple tasks usually do not require
  written procedures at the point of use
• The Matrix provides guidelines for the
  appropriate form of procedural support
• Risk, complexity, frequency of task performance

3
You cannot write procedures for everything

• For routine situations OPERA allows best
  practices can be defined and documented as the
  most cost effective way(s) of carrying out the
  task
• For abnormal situations, job aids must be
  provided for dealing with situations that can be
  anticipated
• For high risk, unpredictable situations, need to
  define generic procedures to get the system to a
  safe state and buy time

4
Three Phases of OPERA

• Develop Best Practice
• Participation not consultation
• Reach consensus
• Make Preferred Practice Best Practice

• Support Best Practice
• Balance between job aids and procedures
• Training assessment linked to Best Practice

• Maintain Best Practice
• Maintain an open culture
• Use feedback to update Best Practice

5
Best Practice
6
Phase 1 Develop Best Practice
Training needsCompetence assessment Level of
support
Tools
Reference Procedure
Stages
Inputs
7
Black books are a useful source of informal,
undocumented knowledge
7
8
How the Consensus Process Works
8
9
(No Transcript)
10
Reference Procedure format
Task analysis information
Potential hazards / consequences
Training issues
Hazard Hazard Hazard Add. Info. Generic skills Specific knowledge Level of support
Add. Info. Generic skills Specific knowledge Level of support

11
Maintaining Best Practice

• Encourage and use feedback from users
• Maintain channels of communication with the sharp
  end via facilitator
• Reapply OPERA to generate new practices and
  supporting job aids refresher training
• plant/equipment changes
• changes in working practices
• operational experience
• regulatory change

12
What are Job Aids?
Any source of information used to support the
successful performance of tasks (e.g reminders
and memory aids)
Intended to complement but not replace skill
13
How often are written procedures actually needed
in hand when a task is performed?
14
The Matrix for determining appropriate level of
support
14
Low
Medium
High
Task Criticality
Freq
Infreq
Rare
Freq
Infreq
Rare
Freq
Infreq
Rare
Task Familiarity
NWI
NWI
NWI
NWI
NWI
NWI
JA
NWI
JA
Low
Task Complexity
NWI
NWI
NWI
NWI
JA
SBS
NWI
JA
NWI
Medium
NWI
JA
JA
NWI
NWI
SBS
JA
JA
SBS
High
No Written Instruction required (NWI)
Job Aid required e.g. checklist/memory aid (JA)
Step by Step instruction required (SBS)
15
Examples of Job Aid Formats

• Step-by-step lists
• Posters
• Flow charts
• Labels
• Simplified drawings
• Decision tables
• Check list sheets

16
UK Plug Cover Job Aid
E
13A
6mm
Green Yellow or Green
L
L
6mm
32mm
Fitted With BS 1362 13A Fuse Always Fit BS 1362
Replacement Cartridge Fuse
Fuse
Brown
or
22
Red
mm
N
12mm
6mm
Blue or Black
Cord Grip
17
Furnace /Hot Oil - Label
Flue gas O2

• Maintain burner pressure above 0.6 bar
• Keep oil temperature 170 - 225C

18
Furnace Trip Job Aid
18
How longis furnace likely tobe down?
19
Planning Job Aids
20
Case Study Improving Procedures Compliance at a
Major Multinational Chemical Site

• Failure to manage flare line incident almost led
  to a catastrophic failure
• Analysis of incident showed that main cause was
  failure to comply with procedures (HSE
  investigation)
• HRA asked to investigate and propose solutions
  across site (1000 employees)

21
Case Study Improving Procedures Compliance at a
Major Multinational Chemical Site

• Phase 1 Procedures culture survey developed and
  applied across site
• Phase 2 Procedures culture change process OPERA
  (Optimising Procedures for Efficiency and Reduced
  Accidents) developed and piloted across site
• Phase 3 OPERA rolled out across all production
  units on site over 4 year period (Owned by
  workforce, facilitated by HRA)

22
agree
Procedures are not used because
40
Dont understand why they are necessary
42
More difficult to do work
72
Instead rely on skills experience
Find a better way of doing them
42
62
Too long if followed to the letter
47
Too restrictive
19
Experienced people dont need them
44
Too time consuming
34
Resent being told how to do job
37
No policy on when should be used
70
Assume have knowledge
23
Most procedures manuals were rarely accessed
23
24
Results of applying OPERA over a 3 year period
Changes in opinions of workforce
Improvement over 3 year period
Opinions Procedures are
 52
Unworkable
19
Not best practice
21
Too complex
17
Identification difficult
18
Not aware they exist
52 
Don't understand why they are necessary
Statistically significant changes
25
Case Study ConcludedWas the process successful?

• Plant start-up time substantially reduced, giving
  500,000 pounds saving in first year
• Many cost reductions due to reduced time needed
  to conduct yearly start-ups/shutdowns
• Generally procedures followed as documented

26
Case Study ConcludedWas the process successful?

• Reduced effluent emissions
• Improved safety record
• After 5 years savings of 3 Million pounds
  produced
• Site now has the highest production levels per
  employee of any site worldwide (Formerly bottom
  of the international league table)

27
Summary of Recommended Strategy

• Start with the most critical tasks (from Task
  Inventory Criticality analysis)
• May use existing procedures as starting point but
  need to verify against actual working practices
• Develop Reference Procedures for the Critical
  Tasks (depending on resources)
• Develop Job aids, training and competency
  specifications to control risks
• Proceed to other tasks as resources become
  available

28
Real Men Dont Use Procedures!
28