When human error leads to operational or equipment failure, RCA investigations often reveal that either a process was in place but not followed or there simply was no written process, Plant Manager Bob Burchfield said in introducing a best practice on how to write effective procedures. Burchfield manages Faribault Energy Park, a 265-MW 1 × 1 F-class combined cycle owned by the Minnesota Municipal Power Agency and operated by NAES Corp, and has been a regular participant in CCJ’s annual Best Practices Awards program.

In his opening remarks, Burchfield noted that technicians and managers generally focus on results and may have limited experience writing procedures. It’s important to sharpen procedure-writing skills, he stressed, because ineffective procedures complicate tasks and contribute to poor performance.

For some processes, like a complex plant startup, a checklist combined with “skill of the craft” knowledge may be more effective than a wordy procedure. However, it may be beneficial to have both a procedure for training and a checklist to better serve the experienced user.

Burchfield urged consideration of the “preflight checklist” shown in Fig 1. If it were written for an untrained crew member or passenger, much more detail would be required. As written for the captain (C) and first officer (F), it includes only minimal cues that enable a well-versed operator to complete the process more efficiently. Spare wording allows such a reader to focus on task execution, thereby reducing the probability of error.

At Faribault Energy Park, management shared fundamental procedure-writing skills with plant personnel and empowered them to draft procedural checklists. Once supervisors and technicians understood the value of these fundamental rules, they wrote more effectively which likely reduced the number of safety incidents and forced outages.

Procedure writing was distilled down to the 10 core elements identified below. An hour-long PowerPoint session was sufficient to explain them in a classroom setting. Slides included comparative examples of good and bad writing techniques. A few advanced writing skills were introduced—such as embedding pictures and graphics to aid a technician in 4-kV breaker racking operations. The value of pictures was further illustrated using an example of a store-bought item labeled “some assembly required” and reviewing how difficult the process would be without pictures.

Other more complicated aspects of procedure writing were intentionally excluded from this first phase of training to maximize retention of the core fundamentals.

 Ten steps to more effective procedures

1. Generally, write one step only on each line. Human-factors studies indicate the reader is more likely to omit or miss a second step if it’s started on the same line as the preceding step.

2. Use a positive action/command in each step. Avoid ambiguities, such as the word “ensure.” A better word choice is “verify.” Reason: The reader must confirm a desired result which may or may not require a physical action.

3. Write in a vertical format, placing each step below the previous one. If the reader’s eyes must leave the procedure and return, it’s more difficult to find where he or she left off if multiple steps are embedded in a paragraph.

4. Use “white space” to separate each step. This makes it easier on the eyes to return to the correct step in the sequence. If each step includes a sign-off line or box, it’s acceptable to omit the line space between steps. The pilot’s pre-flight checklist in Fig 1 is an acceptable example where no spacing is used because it has a sign-off action.

5. Require a check-box or other written confirmation for critical checklists that must be performed in correct sequence—to prevent personnel injury and/or equipment damage, for example. Think about the simple requirement of installing a grounding wire or a bonding strap when connecting or disconnecting hydrogen piping to prevent sparking. Personnel may be unfamiliar with this requirement, which has been a causal factor in burns—even fatalities. A check-marked or initialed verification significantly reduces the probability of missing a safety-related step.

6. Place check-boxes to the right of the step. This forces the reader to read the text before signing off. Conversely, if you place boxes to the left, the reader is forced to read the step and then circle back to check the box—which introduces a greater risk of checking the wrong box or signing off without completing the required action.

7. Select a proper font and size. Some readers have poor vision, and field lighting conditions are almost never ideal. Inexperienced writers tend to reduce font size to fit the procedure on one page, but this defeats the purpose if the procedure is illegible. Avoid using all caps. Studies indicate sequences of upper-case letters are more difficult to read.

8. Use precautions, cautions, warnings, and notes wisely. Precautions are conditions required before starting the procedure and usually apply throughout the entire process. Example: Ambient temperature must remain greater than 40F to perform an offline water wash. Inexperienced writers will enter that precaution in the precautions section only and exclude it from the body of the procedure.  

Here’s the problem with this approach: The “results oriented” operator has a tendency to skip over the precautions and jump to Step 1. In this case, the precaution also qualifies as a verification step. It’s acceptable to duplicate it in multiple sections of the procedure.

This requirement could be written three or more times: (1) as a precaution, because it should be known before starting offline water wash. (2) It also should trigger a caution statement placed immediately prior to applicable step advising that ice may damage compressor blading if temperature is less than 40 degrees during the wash. (3) Immediately below the caution should be a numbered or check-off step requiring forecasted temperature to be verified more than 40F throughout the duration of the water wash.

Cautions and warnings typically are not numbered or treated as an action step but they are “step specific” and must be placed immediately before the step to which they apply. If failure to follow a step can result in injury or death, it should be preceded with a warning statement. Caution statements are used when equipment damage may result.

Notes are amplifying or helpful information and may be placed before or after the applicable step. If failure to follow the “note” can lead to adverse consequences, then it’s probably not a note.

9. Decide if a written control process is needed when reviewing incidents and poor performance issues. Plant personnel are not programmed to recognize a new checklist or procedure may improve the quality of a process. Example: Faribault experienced a few incidents after failing to address recommendations in various third-party reports. Had plant personnel processed each report using a quality-control process, these incidents could have been avoided.

Third-party reports—such as borescope reports, lube-oil analysis, etc—may contain extensive recommendations dispersed throughout dozens of pages. Failure to act on recommendations can lead to undesirable outcomes, such as fines and forced outages. Fig 2 is a checklist developed by Faribault as a guide for processing third-party reports.

10. Field-validate procedures before issuing as “approved” documents. No procedure is ever 100% accurate, especially a brand new one. Test its accuracy and effectiveness in a controlled manner by assigning an experienced person to accompany the user and make corrections.

Results. At Faribault, human errors have been reduced measurably using procedural checklists formatted using these basic rules. The plant is consistently started up and shutdown in an error- free manner.