(113a) Procedural Safeguard Reliability

In the hierarchy of hazard control, an important transition regime occurs when consideration moves from engineering controls to administrative controls and work practices. During this transition, hazard control shifts from reliance upon an engineered system or piece of equipment, to a potentially unpredictable human element. One example of an administrative hazard control commonly used in industry is procedures. A procedural safeguard combines multiple elements (a written document, a human worker, and equipment) into a single safeguard, but it is often unclear to what degree all three elements can be relied upon to operate as intended when needed. In this paper, the topic of procedural safeguard reliability is addressed. Specifically, topics focus on the evaluation of procedural safeguards as it relates to the quality of the written document, the training, experience, and performance of the human using the procedure, and the steps that are necessary to ensure that the procedural safeguard can be relied upon to function as designed. Lastly, case studies will be presented highlighting lessons learned from incidents related to inadequate procedural safeguards.