June 2021


Achieve zero execution errors through procedure clarity

It is well-documented that many unplanned manufacturing events could have been prevented if procedures were executed properly.

Montemurro, F., Voovio Technologies

It is well-documented that many unplanned manufacturing events could have been prevented if procedures were executed properly. Ensuing investigations cite “failure to follow procedure” as the event root cause, resulting in next step recommendations that include additional operator training and discipline.

However, a more systemic failure could be at the root of these unplanned events. When an operational execution error occurs during a process or equipment startup, shutdown, changeover, process loss out of primary containment or other event, how often is “procedure clarity” considered the root cause? This can be considered a major source of error that is overlooked by the industry.

Operating procedures originate during capital project installation and are developed using the technical process design basis. Procedures include safety warnings, specific instructions and details required to complete the desired outcome. Following a project startup, the initial operating procedures are redlined, updated and institutionalized as part of the site’s management of change (MOC) process.

Two major reasons for suboptimal procedure clarity have been identified:

Procedure does not reflect operator practice. The author’s company analyzed 300 customer procedures, the majority of which were startup and shutdown procedures. The data shows a significant number of procedures do not match operator practice, a foundational element for operational discipline. When surveying manufacturing subject matter experts (SMEs), the written procedures vary from the unit’s established practices, with some practices varying from shift to shift. The Ron Moore Group found this causes up to 23% of manufacturing downtime losses (FIG. 1).

FIG. 1. Unleashing the hidden plant. Source: Ron Moore Group.

Ambiguities and generalizations. Using procedures, manufacturing operators train on how to operate the process, unit or plant safely and effectively. Operators are challenged to learn and qualify on hundreds of pages across a range of procedures. Often, these procedures are written with a large amount of technical content, generalizations and ambiguities that assume clear understanding by the operator. Procedures are typically written by engineers or SMEs that are very familiar with the process—these engineers or SMEs can overlook basic details of execution, believing those details are largely understood.

Example: Procedure line with additional peripheral information and options on how to execute the procedure:

“Level indicator transmitters (ABC-111 and DEF-222 at A-C-9 and GHI-871 and GHI-872 at A-C-8) provide an initial inventory in these vessels. To provide initial inventory in A-C-7 and A-C-6, 30-psig condensate control valve (FV-4447) can be manually opened or put in automatic at 30%. The steam regulator for A-C-6 is located beside the CO2 plant.”

The first and third sentences are unnecessary for procedure execution and may add uncertainty for the operator. The second sentence gives the operator options, leaving to question the preferred best methodology to inventory the system.

Examples: General, ambiguous information in procedures:

  • “Close all bleeders and open-ended lines”
  • “Blow product return lines and control valve loop with blend gas from A-123 take-off manifold to ensure lines are clear, then isolate from all equipment”
  • “Outside operator will verify manual valves on feed system are lined up”
  • “Ensure cooling water is lined up to all coolers and exchangers that require cooling water”
  • “Manually close all condensate controllers outside.”

An operator is expected to follow the above procedural statements and remember where “all” components are located while executing the one procedure line item. In the 1990s and early 2000s, this problem was masked by workforce experience; shift teams had many individuals with more than 20 yr of operating experience, so procedure clarity was unimportant. With the present gap in experience, the lack of procedure clarity, and few operator aids to ensure execution accuracy, incidents and unplanned events will continue to occur.

Impact of procedures during operator training

Once an operator reads a procedure, shadows an experienced operator and completes an assessment, they are “signed off as qualified.” Industry data indicates that operators may only have experienced 40% of their procedures because equipment is always running and other priorities. Following qualification, the operator is released to perform the work. Therefore, procedure quality and specificity are the building blocks for developing operator competency.

Procedure formats and templates vary from company to company, even from site to site. Some companies have implemented digital procedure solutions, requiring many plant resources and subsequent procedure conversions. Other companies maintain procedures manually with internal document control systems. Whether operators need to print procedures or take a tablet out in the field and sign off steps as they are completed, both formats require operators to read procedures for understanding.

It is well-documented that individuals learn and retain ~90% using simulation and doing vs. ~10% when reading procedures (FIG. 2). The industry challenge is to move operator training—proactive development—down the pyramid1 to increase individual retention and reduce an operator’s time to full competency.

FIG. 2. The learning pyramid or cone of learning.

Ultimately, to see a step-change improvement in operational discipline, procedures must be developed, implemented and maintained based on successful execution by the end user—the operator—and they should be clear, concise and action-based.

Employing best practices

The author’s company employs two best practices to ensure accurate procedures and standard operator execution. First, a line walk is performed for procedures with the resident SME to accurately document procedure execution using photographs, and an action-based checklist is created. This visual walkthrough identifies gaps in the written procedure and the actual operating practice.

All deviations from the documented procedure are reviewed and approved using the site MOC process. Using the author’s company’s patented technology, users can perform the newly documented procedure in an immersive photo-based environment (called the digital replica) where they can interact and perform the procedure. This simulation allows operators, engineers, production specialists and others the chance to visually verify procedure accuracy.

The second best practice is the addition of action steps, better known as a checklist. This practice has significantly improved safety performance in air travel, medical procedures and other sectors. During the line walk with the SME, each action the operator is expected to complete is confirmed and photographed. Multiple actions are regularly discovered within a single procedure line. Below are two examples:

  • The procedure line item, “Close all bleeders and open-ended lines,” resulted in 12 action steps—12 bleeders and open-ended valves required closing to ensure that no contents left primary containment and/or caused an environmental incident.
  • The procedure line item, “Manually close all condensate controllers outside,” resulted in 20 action steps to close 16 valves.

On average, the author’s company’s process eliminates procedure generalities and ambiguities and results in 2.4 times more procedure steps that are clear and concise, action-focused steps with visual clarity. A summary of past projects is depicted in FIG. 3.

FIG. 3. Improved procedure clarity of past projects.


Operational discipline and speed to operator competency are and will remain competitive advantages due to the current and projected attrition slated for plant sites. Clear and concise procedures, standardized on plant operation that have objective assessments, are foundational building blocks to ensure operator competency. Manufacturing plants can build operator competency and deliver business results safely and successfully by using the established best practices detailed here, combined with the visual clarity that simulation provides. HP


  1. Dale, E., “The learning pyramid,” online: https://en.wikipedia.org/wiki/Learning_pyramid

The Author

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