At what point does the One Point Lesson(s) come down and the critical information become integrated into your permanent work instructions and procedures?
To preface my question: I have witnessed years of One Point Lessons, Visual Aids, "For Reference Only" forms and dozens of other such postings that remain up for months or years, where critical information should have been integrated into the procedures to start with.
While some sites have the One Point Lesson (OPL) information already within a document and use the OPL as a "friendly reminder" on the steps, my response is based on how I have seen some of my organization's sites address your question.
Within our organization, OPL are utlized only when there has been a failure within the system, but the analysis does not require the retraining of everybody on the applicable document or process.
Instead, a OPL is created to address what was done that caused the failure and what should have been done to ensure the process was done properly.
The OPL is issued a unique number and tracked in a log with information such as:
- Date of issue
- Date OPL presented to personnel
- Associated documentation
From there, what is logged for the future is any additional usage of the OPL. If the document is used more than x times within timerange y, then the OPL information is added to the associated document(s).
All of that being said, it is important to remember that the OPL is generated by these sites as a result of a failure analysis (FA). Part of our FA process, is to to review whether existing documentation needs to be revised. If it deemed that the existing documentation contains all the necessary critical steps and that an OPL will suffice, that is the route we take.
If we revise documentation, personnel are trained on the new document and an OPL is not created.
