PTQ Q3 2026 Issue

Procedure management in refinery operations

Document-based management models are structurally inadequate to maintain the quality, currency, and execution fidelity that safety-critical operations require

Giulio Cattarin Octave

E ffective procedure management is a critical element of safe and efficient refinery operations. Procedures guide steady-state control of process units, define how systems transition between operating states, and pre- scribe actions under abnormal or hazardous conditions. Standard operating procedures (SOPs) govern the day- to-day operation of a refinery. SOPs have been described as “foundational tools (...) to ensure consistency and effi- ciency in the execution of tasks.” As Johnson et al. (2025) noted, “SOPs dictate routine and emergency practices, encompassing purpose, terminology, roles and step-by- step instructions detailing how to perform complex oper- ations safely, effectively and consistently, thus forming the backbone of industrial safety management.”1 When procedures are current, accessible, and consist- ently followed, they function as a primary defence against human error and operational variability. When they are incomplete, outdated, or disconnected from field practice, they introduce systematic risk. The Health and Safety Executive (HSE) guidance notes that problems with proce- dures are frequently cited as contributory factors in major accidents, often linked to inadequate design, maintenance, or use of procedures.² Evidence from industrial incident investigations consist - ently identifies procedural deficiencies as a contributing factor in serious accidents, including a 2022 fatal naphtha release at a refinery in Oregon, Ohio, and the 2018 explo- sion of an FCC unit at a refinery in Superior, Wisconsin.³ This observation aligns with HSE human factors guid- ance, which identifies failure to implement procedures prop- erly as a recurring causal factor in incidents, often driven by gaps in training, communication, or understanding. Beyond safety risks, procedure failures can also lead to major financial losses: incident data from five refineries and petrochemical plants collected over a three-year period by the Abnormal Situation Management (ASM) Consortium attributed $12 million in losses to procedure-related failures.⁴ Incomplete coverage, defined as procedures that do not address the situation an operator encounters, represents the single largest failure category at 42.7%. A further 29% of failures involve procedures that existed but were not fol- lowed. Together, these two categories account for approxi- mately 72% of procedural failures and indicate two distinct

but related management challenges: the quality and com- pleteness of procedure content and the organisational con - ditions under which procedures are used in the field. Today, adverse demographic trends exacerbate the need for better procedure management. With one-fifth of its workers above the age of 55,⁵ the oil and gas sector sees large volumes of operational knowledge lost to retirement. A substantial portion of this knowledge exists as tacit expertise, such as operator-specific adaptations and inter- pretations that are not captured in formal documentation. Without active mitigation, the attrition of this knowledge base progressively erodes both the quality of procedure content and the informal correction mechanisms that have historically compensated for procedural gaps. Incomplete coverage, defined as procedures that do not address the situation an operator encounters, represents the single largest failure category at 42.7% While 69% of oil and gas companies say their procedures are digitally available, this digitisation still largely relies on traditional document management methods, such as PDF documents stored in shared network directories.6 For example, Crossbridge Energy, operator of a refinery in Fredericia, Denmark, which supplies more than a third of the country’s liquid fuel, relied on legacy storage systems prior to its 2021 modernisation programme. Procedures were maintained in spreadsheets and printed for field use. Operator annotations accumulated on working copies but were not systematically consolidated into master documen- tation. Manual periodic checks of the existing knowledge base were required to identify documents due for review, a process reported as difficult to maintain consistently. Similar conditions characterised the procedural environ - ment of a major global energy operator prior to its mul- ti-year digitisation programme. Different operational teams Procedure management in refineries Predominant practices

PTQ Q3 2026