Discussion Central

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? 

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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.

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.

• 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.

• 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.

• 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.

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.