What does a best practice SOP look like? Don’t bother to answer the question. It matters less than this: who wrote the SOPs; how are they kept up-to-date?
The quality of SOPs (and indeed any part of a SMS) is made or broken by process: the process to create the SOPs, the process for up-dating them.
Here is a story that reveals the answers to the question that matters. This account once was confidential, but I hope it isn’t now. For profound insights are revealed.

I was a member of the Human Factors Study Group of the Health and Safety Commission’s[1] Advisory Committee for Safety in Nuclear Installations (ACSNI) in the early 90s. We published a report “Organising for safety”[2].  An earlier blog describes the work of the Group

Before our report was published, the Group visited neighbouring nuclear power stations, designated here Station A and Station B.  Station A was at that time the ‘worst’ performing station and Station B had the ‘best’ safety record.   I’m sure things have changed at both sites in the last 25 years.  In any event the Safety Manager at A was a stickler for accident reporting.

We were not told which of the two Stations was the ‘safest’, and we were asked to rank-order them: not a taxing task as it turned out.

The semi-structured site interviews

Each Station had about 300 maintenance staff.  We interviewed the Maintenance Manager, a foreman and a fitter at both stations.  Note that the latter four were nominated, so their views might not have been representative.  Quotes and paraphrases are approximate, but give the gist of what was said.  Expletives have been bowdlerised.  One important confounding factor was that Station B was much newer.

The Station A Manager explained that he was over-burdened by paper work and very rarely had an opportunity to go ‘on site’, to his regret.  He told us that they only recruited highly competent fitters (which they were) and there was no need for an induction training programme.

He further said that the SOPs were under the control of the Safety Manager.  He had given up trying to get them changed because of the bureaucracy involved.  The fitter we spoke to simply said “the procedures are out of date and we ignore them.  We just do our best”.  Fitters were apparently violating the rules simply because they could not be complied with.

In sharp contrast the Station B Manager said that however busy he was, he always spent half-a-day a week ‘on site’ talking to his staff individually and in ‘tool box’ discussions, and generally finding out what was going on; dealing with any concerns.  He said that an induction programme was necessary despite recruiting very able staff because it was important that new people understood “the way we do things round here”.  As an afterthought he said that the station was “a big place and it was easy to get lost”.

When asked about SOPs, the Station B Manager said the fitters and foremen wrote them!  We first thought this was hyperbole.

But the fitter explained how it was done.  “When we get a new job, we all meet in the mess room and write the SOP on a flip chart.  Usually when we try it out there are problems.  So we get together again and modify it.  Only when the job has been done five times without any errors is it ‘signed off’”.  But as soon as someone reported a new problem, the SOP was revised, with the process just described.  Supervisors and safety people participated in the discussions, but did not dominate.  The effectiveness of the process depended on fitters reporting that they had to ‘violate’ the rules which they did, without threat of reprisal.

The final interview was with the Station A foreman.  We asked if he could recall any ‘critical incidents’ with permits to work (a time-limited SOP).  He replied as follows:

“Oh yes.  We had a new fitter and I signed off his permit to dismantle No 3 boiler.  About an hour later he came back and said to me ‘Gaffer, that boiler I’m dismantling – it’s bloody hot, you know!’  The incompetent plonker was dismantling the wrong bloody boiler!  I gave the damned fool a piece of my mind.” 

This beggar’s belief: an inadequately inducted fitter was blamed for an unwitting error which could have had serious consequences, a scald when opening a flange perhaps the least serious.

What we learnt

This experience had many learning points:

  • The SOP process at Station B was an object lesson in an effective procedure for managing change. The SOPs were living documents, kept up-to-date.  Moreover the fitters and foremen – the real experts did not just participate; they took the lead in the key decisions.
  • The procedures depended on good communications, and even minor problems were reported – possibly a portend something more serious. Fitters had ‘ownership’ of the way the work was done.  This is in essence the process for effective management of safety rules set out by Andrew Hale in research conducted for IOSH.
  • At Station A the SOPs I’m sure, read well on paper. But the process was deficient.
  • A corrosive blame culture in Station A seems evident. Incidentally routine violations might have been condoned by supervisors – except after an accident.
  • A factor that might be relevant was that the Station A Safety Manager was a man of commanding presence with strong views expressed assertively. In contrast the Station B Safety Manager was self-effacing to a fault and probably saw his role more as an adviser and facilitator.
  • Perhaps the most surprising finding was that the culture in the two stations was dramatically different, despite their proximity and that both were ‘subsidiaries’ of the same parent company. There were serious problems in management and practice at Station A.  The solution lay across the road.

Unfortunately we were not permitted to include the account in our report, though it provided reassurance that our conclusions about the importance of organisational culture had face-validity.

The lesson for you?  If you want great operating procedures that work in practice and are followed by committed employees, make sure the process you use to develop and keep them up to date is carried out to the greatest practicable extent by the employees that have to use them.  Give them as much help as they need but no more.

If you want help you may find Hastam’s course on creating user friendly health and safety documentation is just what you need.

[1]      Now part of HSE of course.

[2]      HSC (1993) “Advisory Committee for Safety in Nuclear Installations Human Factors Study Group Third Report: Organising for Safety” HMSO London; (out of print); Booth RT & Lee TR (1995) “The Role of Human Factors and Safety Culture in Safety Management” Proc Inst Mech Engrs Vol 209 pp 393-400.  The latter is a ‘de-nuclearized’ version of the HSC report focussing only on the key themes.


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