A significant amount of time and effort in manufacturing operations is
directed toward the development of procedures intended to ensure that
work activities are carried out in a safe and efficient manner. Despi
te the often high level of investment, however, it appears that there
are a number of problem areas associated with procedure use where the
systems frequently fail to meet their intended objectives. The cost of
failures in a procedure system can vary quite widely dependent upon t
he nature of the operation. In most cases the consequences of failure
have only a negligible effect on the overall performance of a company
and can be measured in terms of production hours. Occasionally, howeve
r, the consequences of failure can be catastrophic and result in signi
ficant damage to people, plant and the environment. The purpose of thi
s paper is twofold: The first objective is to provide a preliminary re
view of common problems which are associated with the catastrophic fai
lure of procedure systems in a manufacturing environment. The second a
im is to consider some of the ways that a human factors approach might
be used to help prevent the more serious failures associated with the
use of procedures in industrial settings. Relevance to industry A rel
iable and well-managed system for procedure design and use is an impor
tant component in a safe and efficient manufacturing process. Poorly d
esigned procedures may be misinterpreted or even ignored by management
and-operational staff, which in turn can result in major incidents in
volving human casualties and production loss.