Procedures not followed

It is usual, before a piece of equipment is maintained, to give the maintenance team a permit-to-work that sets out  

This section describes incidents that occurred because of loopholes in the procedure for issuing work permits or because the procedure was not followed. There is no clear distinction between these two categories. Often the procedure does not cover, or seem to cover, all circumstances. Those concerned use this as the reason, or excuse, for a shortcut, as in the following two incidents  

1 Equipment Used After a Permit has Been Issued 

fiaP MftW6 HBS dibWt to.ItI have been called in. Except in an emergency, plant operations should never be carried out while a 

It is bad management for those issuing work permits to cover themselves by asking for more protective clothing than is really necessary. They should ask only for what is necessary and then insist that it be worn. 

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Engineering and administrative requirements for safe storage, including the full range of consequences should requirements not be met or procedures not followed... 

Procedure not followed Staining steps were not performed in the correct order. Specimen pretreatment protocols such as digestion or microwave heating were not followed. Review manufacturer s package inserts. 

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. 

Rule-based performance requires following preset solutions then taking prearranged specific actions. This performance uses an If-Then decision-making process. If X occurs, then Y is required (US DOE, 2009a). The JHA defines scenarios where standard operating procedures, rules, guidelines, and structure are essential. Errors can possibly occur when rules or protocols are misinterpreted or established procedures not followed or understood. 

Procedures are written to ensure that activities are performed in a systematic way. Accident investigation shows that the majority of accidents occur because procedures are not followed, and this contributes mostly to the base of the safety triangle introduced at the end of Section 4.1. 

I la2g la2y 2a2g 2a2 and all single and double excitations relative to this (dominant) CSF, which is a very common type of Cl procedure to follow, the Bc2 wavefunction would not have contained the particular CSFs ls2 2p2 ls2 2p2 b because these CSFs are four-fold excited relative to the la2g la2y 2a2g 2a2 reference CSF. 

Avoid the temptation to overreact after an accident and install an excessive amount of protective equipment or complex procedures which are unhkely to be followed after a few years have elapsed. Sometimes an accident occurs because the protective equipment available was not used nevertheless, the report recommends installation of more protective equipment or an accident occurs because complex procedures were not followed and the report recommends extra procedures. It would be better to find out why the original equipment was not used or the original procedures were not followed. 

Many accidents have occurred because the two procedures discussed in the following sections were unsatisfac toiy or were not followed. 

Lines are not Follow operating procedures depressurized, Install pressure indication instrumentation and before checking, changing filters. CCPS G-3 CCPS G-22 CCPS G-23 CCPS G-29... 

Repacking the pump is a difficult and dirty job and falls down to the bottom of the mechanics favorite to do list. Extreme eare should be taken to assure a proper installation. It s a job usually put off until the very last moment. Repaeking a pump eorrectly takes a lot of time. Not following the correct repacking and start-up procedures results in short packing life. 

Not everything you do can be proceduralized. Some policies can be implemented without a procedure. The following are examples of such policies ... 

In both incidents, the procedures were poor and were not followed. It is unlikely that the accidents occurred the first time this happened. If the managers had kept their eyes open, they might have seen that the procedures were not being followed. 

Use the incidents to train new staff, managers, foremen, and operators so they know what will happen if they do not follow recognized procedures and good operating practice. 

Root causes 1,2, and 3. Procedures were not followed. Procedures were not written down and in practice were inconvenient to use. No audit was made to verify the usability of the procedures. 

On the basis of the information contained in a step-by-step procedure, a checklist can be designed consisting of active checks for critical steps which operate as an "aide memoir." Experienced workers who normally carry out a task from memory may forget isolated acts or inadvertently not follow the correct sequence of steps in the procedure. 

For the most part, future trends will be found in liazard accident prevention, not liazard analysis. To help promote liazard accident prevention, companies should start employee-training programs. These programs should be designed to alert staff and employees about tlie liazards tliey are exposed to on tlie job. Training should also cover company safety policies and tlie proper procedures to follow in case an accident does occur. A major avenue to reducing risk will involve source reduction of hazardous materials. Risk education and communication are two other areas tliat will need iniprovemcnt. 

Finally, any training is incomplete without proper validation of the trained model. Therefore, the trained network should be tested with data that it has not seen during the training. This procedure was followed in this study by first training the network on one data set, and then testing it on a second different data set. 

Administrative procedures Administrative procedures often become points of difference, especially when not followed. 

For many purposes an exact pH value is not required it suffices if the pH of the solution lies within an appropriate pH range and examples will be found in the text of details of buffer solutions required for particular procedures. The following are illustrative of buffer solutions covering a range of pH values. 

Standard States of Solutes in Solution For a solute, particularly in situations where only dilute solutions can or will be considered, the usual procedure is to define the standard state in terms of a hypothetical solution that follows Henry s law at either a concentration of. y2 =1 or mi = 1. These standard states are known as Henry s law standard states. The standard state solutions are said to be hypothetical because real solutions at these high concentrations do not follow Henry s law. 

When Hie denominators are not the same, for example, comparing 2/3 and 1/10, the lowest common denominator must first be determined. The same procedure is followed when adding fracfions with unlike denominators (see above). 

The rate of copolymerization in a binary system depends not only on the rates of the four propagation steps but also on the rates of initiation and termination reactions. To simplify matters the rate of initiation may be made independent of the monomer composition by choosing an initiator which releases primary radicals that combine efficiently with either monomer. The spontaneous decomposition rate of the initiator should be substantially independent of the reaction medium, as otherwise the rate of initiation may vary with the monomer composition. 2-Azo-bis-isobutyronitrile meets these requirements satisfactorily. The rate Ri of initiation of chain radicals of both types Ml and M2 is then fixed and equal to 2//Cd[7], or twice the rate of decomposition of the initiator I if the efficiency / is equal to unity (see Chap. IV). The relative proportion of the two types of chain radicals created at the initiation step is of no real importance, for they wall be converted one into the other by the two cross-propagation reactions of the set (1). Melville, Noble, and Watson presented the first complete theory of copolymerization suitable for handling the problem of the rate. The theory was reduced to a more concise form by Walling, whose procedure is followed here. 

Setting times and hydrolytic stability of these cements are given in Table 8.3. In some cases the speed of reaction was very high, and practical cements could not be formed from ZnO or CaO even when these oxides were deactivated by heating. All the faster-setting cements exhibited good hydrolytic stability. The stability of the complexes between divalent cations and PVPA was found by a titrametric procedure to follow the order Mg Ca < Cu Zn (Ellis Wilson, 1991). This result was... 

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