Pitfall 2 – "Wiggle Room" in Systems and Procedures



This blog is the second in a series of five pitfalls associated with management of major hazards. Each pitfall, if not avoided, could lead to a disaster – so please make notes and weave some or all of my recommendations into your safety management plans.

Identification of these pitfalls has occurred over my 30-year+ career helping companies manage their major accident risks and are based on very personal experiences where sound management failed. In the first blog, I expressed how all major accidents harm not only the company, but the workers, their families, and – in many cases – the public. The first pitfall revealed the problems associated with not having a system to assess risks quantitatively. Here, I discuss the importance of having clear systems and procedures in place so that everyone understands his/her role, expectations, and where to go or what to do if questions arise.


Failure to have clear systems and procedures in place can be dangerous, as was the experience at the Longford Gas Plant in Australia on September 25, 1998. Basically, very hot oil (450°F) was pumped into a heat exchanger that was set at a very low temperature (-55°F). The combination caused brittle fracture and a release of approximately ten tons of hydrocarbon vapor. This vapor ignited, setting off a huge fire. Two people died and eight were injured.

As is often the case with accidents, the company tried to blame the workers. It claimed they didn’t apply the procedures that they were trained to apply.

The Royal Commission disagreed!

Its investigation concluded that Esso’s management system failed the workers, and not the other way around. The Operations Integrity Management System (OIMS), combined with all supporting manuals, was a complex management system that was difficult for management to understand, let alone the workers. The Royal Commission Report also concluded that the procedures were deficient.

When systems and procedures are complex, unclear, and difficult to understand they are difficult to follow and implement –  things can then go terribly wrong – as workers witnessed at Longford.

Clear systems and procedures are an essential part of any utility or energy company’s internal control system and are key factors in the safety, security, and health of workers, the environment, and the community.


There are a few characteristics that good systems and procedures possess that makes them way more useful. It may seem obvious – and it is – but so many companies seem blind to them.

In one project that I was on in Australia, there was a drive for “wiggle room.” Let’s not be too specific or clear just in case we choose not to, or deliberately don’t, follow what we say.

Clear. Systems and procedures must be understandable by all levels of the organization from management through to the shop floor – the workers who carry out most of the physical work and have to follow these procedures.

• Detailed. Clear does not mean simple. Systems and procedures must be explained thoroughly and with enough details that allow the user to comprehend exactly what needs to be done and why. It’s in the details where the complex becomes understood.

Who, what, when, and why. Those details must include who does what, when, and why. Why is often a key factor left out in an effort to be brief, but it is imperative – people who understand why something is being done, tend to comply with the requirements more often.

These three characteristics may read as though they are easy enough to implement, but a word of caution: it takes time and considerable thought to provide a clear, detailed, thorough management system. At G2 Integrated Solutions, we are committed to providing our clients with the solutions they need for their risk and integrity management systems.