An operator repeatedly uses a handwritten startup checklist that differs from the approved procedure. What is the best initial action?

When an operator uses an unapproved procedure, it signifies a "normalization of deviation." The immediate priority is to stop the work to prevent a potential incident. The best action is to investigate why the deviation is occurring. The operator's checklist may contain valuable improvements because the approved procedure is outdated, incorrect, or difficult to use. Reconciling the field practice with the approved procedure and the original design intent allows the organization to identify and correct deficiencies in the formal system, capture valuable operator knowledge through a proper Management of Change (MOC) process, and reinforce a positive safety culture.

A. Automatically discipline the entire shift without investigation: This is punitive, damages safety culture, and fails to address the root cause of the procedural discrepancy.

B. Ignore it because the operator is experienced: This normalizes deviation and accepts an unknown level of risk, which has been a factor in major industrial accidents.

D. Destroy the approved procedure: This is an irrational action that eliminates the established safety standard without a proper review or replacement process.

1. Center for Chemical Process Safety (CCPS), "Guidelines for Risk Based Process Safety," AIChE, 2007, Chapter 11, "Conduct of Operations," Section 11.2.1. This chapter emphasizes that "procedures are to be followed rigorously" and discrepancies must be resolved before continuing work.

2. Hopkins, A., "Failure to Learn: The BP Texas City Refinery Disaster," CCH Australia, 2008, pp. 35-40. This publication discusses how procedural violations and normalization of deviation were causal factors in the disaster, highlighting the importance of addressing such discrepancies.