Inadequate procedures

Butikofer (1986) Accidents in petrochemical and refinery units equipment and design failures 41% personnel and maintenance failures 41% inadequate procedures 11% inadequate inspection 5% other 2%... 

The traditional approach, because it sees the major causes of errors and accidents as being attributable to individual factors, does not encourage a consideration of the underlying causes or mechanisms of error. Thus, accident data-collection systems focus on the characteristics of the individual who has the accident rather than other potential contributory system causes such as inadequate procedures, inadequate task design, and communication failures. 

A characteristic of the PIFs that follow is that although they may not affect performance in a direct manner, they may interact with other factors such as inadequate procedures, training, and worker experience to give rise to errors. 

We mentioned above that it is possible to carry out carbon-carbon correlation experiments using the 2D INADEQUATE procedure. There, as you may remember from the discussion of one-dimensional INADEQUATE, we have a very difficult problem to solve carbon-13 represents only 1.1% of the total carbon nuclei present in a sample. And in the INADEQUATE experiment we need to detect only those molecules containing two carbon nuclei which couple with one another, i.e. about 10"4 of the nuclei present at the same time we have to get rid of the signal coming from those molecules containing only one carbon-13 (the great majority) ... 

Inadequate procedures for storage/handling of reactive chemicals 17 46... 

Failure to comply with cGMP requirements is just one of the areas during clinical trials that may result in compliance issues. Improperly assigned expiration dates, inadequate procedures related to the extension of expiration dates, and abreakdown in any of the steps from manufacture of a clinical trial material to its use in a clinical trial could result in compliance issues. Starting with the manufacture of clinical trial material, there must be well-designed and documented procedures that effectively involve all appropriate persons and departments to assure that only material within specifications is used in clinical trials. There must be procedures that ensure the timely availability of clinical supplies, timely and appropriate extension of expiration dates, timely investigation of out-of-specification (OOS) results and rapid notification of appropriate persons, timely recall of all OOS and expired materials, and timely resupply with fresh materials. Depending on the severity of the compliance issue, the clinical trial could be considered compromised. 

Inadequate procedures (OP) imply improvements in the area of procedures. 

QA s task to identify noncompliance with regulatory requirements, the trial protocol and internal procedures such as SOPs is not always an easy job. Communicating deficiencies and highlighting inadequate procedures is certainly a benefit for the company as a whole, but the individual may not appreciate being confronted with audit findings (Winchell, 2004). In order to be efficient and effective in QA, the following should be observed. 

Contamination attributed to inadequate procedures, or procedures not being followed, or insufficient operator training. 

Causes and lessons learned are reported in only 20 percent of the 167 incidents. (Industry associations, government agencies, and academia typically do not collect this information.) However, more than 60 percent of the incidents for which some causal information was available involved inadequate practices for identifying hazards or conducting process hazard evaluations nearly 50 percent involved inadequate procedures for storage, handling, or processing of chemicals. ... 

Several attempts were made to prepare the nitrostyrene from this aldehyde and nitromethane. The most successful, but still inadequate, procedure is described here. A solution of 1.0 g... 

Inadequate procedures were specified and enforced for how the shadow crew would instruct the new crews. 

FIGURE 6. Example of high level performance measures with constant baseline assumed and poor reporting timeliness (poor) (a) near misses and safety concerns (b) inadequate procedures/procedures not followed. 

In recent years, there has been a growing interest in the determination of trace elements and their species in the natural environment and a number of excellent reviews have appeared on this subject (31). The many precautions required to obtain representative, reliable data and to interpret this data have been stressed a number of times (39). Much unreliable data has been produced because of inadequate procedures to avoid contamination. 

Systematic failure sources are almost always design faults, usually due to inadequate procedures or training. Occasionally however, a maintenance error or an installation error causes a systematic failure. The exact source of a systematic failure can be obscure. Often the failure will occur when the system is asked to perform some unusual function, or perhaps the system receives some combination of input data that was never tested. 

As mentioned by Swain and Guttmann (1983), human reliability is the probability of the successful conclusion of a procedure or task by the operator or team in any stage of the system operation, considering the minimal necessary time (when the time dimension is relevant). Human reliability analysis (HRA) evaluates human actions in a system, considering the factors which contribute to his performance, and it commonly shows incompatibilities among human limitations and the conditions imposed by work. Some of these factors are related to time restrictions, excessive workloads, inadequate training of operators, inadequate procedures, task complexity, and so on. 

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