Discussion Central

  • 1.  Operational Discipline

    Posted 08-14-2019 17:09
    In the CCPS definition of Operational Discipline:

    The performance of all tasks correctly every time.

    what does "correctly" mean to you?

    Steve Cutchen
    US Chemical Safety Board
    Houston TX

  • 2.  RE: Operational Discipline

    Posted 08-15-2019 08:17
    From my own experience of managing a facility before, "correctly" in the context of Operational Discipline is about ​performance to standards. A standard could be anything from procedure, training, practice, etc.

    Anh-Thy Tran
    Global Process Technology Sourcing Manager
    The Lubrizol Corporation
    Solon OH

  • 3.  RE: Operational Discipline

    Posted 08-15-2019 09:36
    Steve - very broad question but a good one.  I Agree with Anh on performance to standards but we all know that there are various level of standards and the level of absolute compliance should vary.  It is imperative that management identify high risk operations where any deviation is not acceptable while, in the interest of efficiency and effectiveness low risk procedures may allow more variation.  The submarine force we did this with the nuclear work/operations - many areas around reactor safety required two person check offs and more reviews while the low pressure steam systems had lower levels of controls - but these were identified by the procedure type and the actual steps in the procedure.  If we tried to apply the nuclear standards to all work, the time and personnel would not be available.  In summary if management does not take the time to properly train and provide the documents/standards that are appropriate the worker will be forced to make decisions on compliance that can be hazardous for them.

    Gary Hilberg PE
    Continuum Energy
    Cypress TX

  • 4.  RE: Operational Discipline

    Posted 08-15-2019 11:51
    I like Gary's wording. Where something is absolutely mandatory, procedures should make that clear and "correctly" would require that the action be performed exactly as prescribed. In most cases, room should be left for improvisation to match the circumstances, and "correctly" means the task is completed in a timely manner, cost effectively, and with little or no risk to people, the environment, or the facility. To achieve optimal performance, "correctly" has to be determined situationally. Regulators, in my experience, don't always like that answer.

    Steven Osborne
    Luling LA

  • 5.  RE: Operational Discipline

    Posted 08-16-2019 00:25
    Edited by Steve Cutchen 08-16-2019 00:26

    Here's my concern with "the performance of all tasks correctly every time:"

    The term "correctly" is judged after the fact. The seeds of this are here in the comments. Sometimes it means "by the procedure" but sometimes it doesn't.  Sometimes there is room. That minefield is up to the operator to navigate in real time.

    Judging occurs after the fact, and leads to Outcome Bias (see below), assigning hero versus failure. If it worked out, it was done correctly.

    Hindsight bias (see below) can then be used to place blame. 

    At GCPS, I've heard Operational Discipline commonly defined as "Always follow the procedure" and Discipline come to mean "a punishment inflicted to correct disobedience, poor behavior, or poor performance." Operational Discipline becomes Discipline of Operators.

    Leadership can fall from enablement to enforcement. A search through the binders and we can find a violated procedure.

    What happens in Abnormal Operations situations; unplanned, where there are no procedures or which cannot even be proceduralized? These Abnormal Operations are the initiating event for most incidents. 

    if Operational Discipline is a keystone for assuring process safety, and if it is limited to 'Always Follow The Procedure,' how does it help in the majority of process safety incidents that are not or cannot be proceduralized? 


    Outcome Bias: the tendency to evaluate prior decisions according to whether the outcome was good or bad. A common belief is that bad events can only arise as the result of bad decisions, and conversely. But history teaches us otherwise: good decisions can still have bad outcomes 

    Hindsight Bias: the tendency to view past events as somehow more foreseeable to the people on the spot than they actually were. This is one of the reasons why what seem to us to be obvious warning signs are often ignored. But such warnings are only effective if the participants know what kind of bad event they are headed for, and this is rarely the case. You do what makes sense at the time. So do other people.

    Steve Cutchen
    US Chemical Safety Board
    Houston TX

  • 6.  RE: Operational Discipline

    Posted 08-16-2019 17:02
    The problem with "correctly" is that, by itself, it is subjective. If we want things done "correctly," we have to make the requirements objective. "Correctly" is typically situational.

    In general, I divide practices into guidelines, policies, standards, and procedures. Others may have different divisions or specifications.

    Guidelines may apply to any of the other three. They typically exist to save time or money and are not required to be safe, to be environmentally sound, or to avoid damage. Application of guidelines is up to the operator. There's nothing specifically "correct."

    Policies are broad statements of organization objectives. For example, we will comply with all published environmental regulations. There is obviously a "correct" response, but objectivity is lacking because the statement is too broad to measure.

    Standards provide steps required to comply with the policy. For example, placing equipment in service requires that all instrumentation is operable and all vents and drains are closed and capped. This appears measurable, but it does not necessarily provide enough guidance to ensure "correctness." Holding an operator accountable for meeting this standard would probably be unfair and unjust.

    A procedure describes exactly what must be done to comply with the policy. For example, Instruments A, B, and C must be placed in service and, if necessary, here are the specific actions required to ensure that happens "correctly." Likewise, drains 1d, 2d, and 3d and vents 1v, 2v, and 3v must be closed and capped "correctly." This may appear burdensome, but how can an operator be held accountable if we do not specify exactly what we need and expect?

    If leadership is unwilling to do the work -- and I can testify that fully-developed procedures are a LOT of work -- to identify what is "correct," they cannot justifiably hold operators accountable. 

    I have found that fully developed procedures uncover many potential Abnormal Conditions. When I write a procedure, I ask myself at each step what happens if flow, pressure, temperature, etc. deviates from the expected. The responses may most often be guidelines rather than procedures, but that's OK. We cannot anticipate all Abnormal Conditions, no matter how smart or experienced we are. We cannot hold operators accountable for "correct" action unless we can define fully what "correct" action is. That probably doesn't satisfy regulators (corporate or government), but it ensures justice.

    Being "correct" is not always appropriate. Operators must understand their processes (and themselves) well enough to be able to address complex problems when they arise. I know the urge to second guess is sometimes overwhelming, but it has to be resisted. There is a difference between second-guessing and working toward a root cause. If we do not make that clear to our organizations, we are not "correct."

    I've rambled enough. That's probably "incorrect."

    Steven Osborne
    Luling LA

  • 7.  RE: Operational Discipline

    Posted 08-19-2019 10:47
    Edited by Steve Cutchen 08-19-2019 10:51
    The incompleteness of "The performance of all tasks correctly every time."  is evident in Steven Osborne's reply. Procedures, Work-As-Imagined, must provide exact steps for compliance with a policy in order to hold operators accountable. Yet, "The performance of all tasks correctly every time." is not always appropriate because of complexity.  So we're back to Outcome and Hindsight Bias, and operators being caught in a blame-resulting Catch-22.

    As Steven points out, the problem is difficult enough when dealing with Routine and Non-Routine Operations, which can at least be proceduralized.
    • Routine Operationis planned, normal day-to-day operation, following established procedure.
    • Non-Routine Operation is also planned and follows established procedures, but it is carried out infrequently, only when needed. When the need arises, pull the procedure from the shelf, verify it, and execute it.
    But what happens with the unanticipated needs arise to:
    • resolve conflicts,
    • anticipate hazards,
    • accommodate variation and change,
    • cope with surprise,
    • workaround obstacles,
    • close gaps between plans and real situations,
    • detect and recover from miscommunications and misassessments.
    This is Abnormal Operations where there is not a precise policy and a procedure cannot describe exactly what is to be done for compliance
    • Abnormal Operation is unplanned, and there is no established procedure. It is distinct from Emergency Conditions. (The CCPS has guidelines for writing Emergency Operating Procedures, e.g., what to do after a loss of containment.) The response is cognitively developed at the time of need. An example abnormal operational response could be assembling an expert team, reviewing and establishing safe operating boundaries, and establishing the criteria for continued  troubleshooting versus shutdown. The Management of Change process should be used to guide the process as hazards are addressed and responses are probed. Or it might require a more rapid response of a smaller team or even an individual.

    If Operating Discipline is to be what CCPS calls "the second most important aspect of process safety culture" (the first being personal involvement by executives), it HAS to encompass much more than "always follow the procedure correctly." It HAS to be relevant when procedures don't exist. A successful Operational Discipline has to work BELOW Procedures in the Hierarchy of Controls; it has to be capable as a non-procedural, Residual Reduction control, like Stop Work. 

    It turns out CCPS has this covered, it's just gotten lost in the push for "follow the procedure or else." 

    This definition of Operational Discipline includes a collaborative and disciplined approach during times when procedures do not exist or are incorrect, and includes the following:

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

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

    This is not Discipline as in "a punishment inflicted to correct disobedience, poor behavior, or poor performance." This is Discipline as in "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 abnormal, unanticipated, or inaccurately specified operational situations arise, this Operational Discipline framework is the basis for residual reduction safeguarding by the Operations team as they respond through RESILIENCE, where Safety does not just mean the condition where adverse outcomes are minimized. It also means the condition where adaption and recovery to safe conditions are maximized.

    Steve Cutchen
    US Chemical Safety Board
    Houston TX

  • 8.  RE: Operational Discipline

    Posted 08-19-2019 11:51
    Good work!

    The principles outlined too often don't work because someone or the organization thinks BLAME has to be assigned. It is often easier to blame than to solve the underlying problem. The productive and profitable response, of course, would be to solve the problem and prevent its recurrence. I don't know why professionals cannot see that.

    Steven Osborne
    Luling LA