Standard Arbitrary Practice (SAP) vs. Standard Operating Procedures (SOP): The Hidden Threat to Organizational Structure in Oil and Gas
- kapilramjattan
- Nov 14
- 8 min read
The difference between a safe, resilient organization and one teetering on the brink of catastrophe often lies in a single letter: the 'A' in Standard Arbitrary Practice (SAP). While Standard Operating Procedures (SOP) are the documented, approved blueprints for safe and efficient work, SAP represents the insidious, informal, and often dangerous shortcuts that erode organizational safety from the bottom up. In high-hazard industries like oil and gas, this procedural drift is not merely an inefficiency; it is a direct pathway to disaster.
The Organizational Erosion: When SAP Replaces SOP
Standard Operating Procedure (SOP) is the controlled, versioned, trained, and auditable way of doing hazardous work. It is a product of reasoned judgment, risk assessment, and technical expertise, designed to ensure consistency, quality, and safety in routine tasks.
Standard Arbitrary Practice (SAP) is the informal, undocumented “this is how we usually do it” habit, shortcuts, tribal knowledge, and improvisations that drift away from what’s written (or fill the void if nothing is written). It is the practical drift—the slow, incremental departure from the SOP driven by convenience, production pressure, or a lack of understanding of the underlying risk.
Feature | Standard Operating Procedure (SOP) | Standard Arbitrary Practice (SAP) |
Basis | Reasoned judgment, risk assessment, and technical expertise. | Personal whim, convenience, impulse, or production pressure. |
Documentation | Formal, written, approved, and controlled. | Informal, undocumented, passed down verbally ("the way we do things here"). |
Goal | Consistency, safety, quality, and regulatory compliance. | Speed, perceived efficiency, and circumventing perceived bureaucratic hurdles. |
Impact | Builds a robust safety culture and operational excellence. | Creates a gap between "work as imagined" and "work as done," leading to systemic risk. |
When SOPs are thin, outdated, or optional and SAP takes over, the result isn’t just inefficiency. It’s structural risk: confused handovers, inconsistent permits, improvised maintenance, unsafe startups, and leadership getting false assurance from lagging Key Performance Indicators (KPIs) until a major incident reveals the reality. This phenomenon is often described as the dangerous gap between "work as imagined" (the formal SOP) and "work as done" (the informal SAP) 11.
The lack of properly defined and enforced SOPs from the bottom to the top level creates a vacuum that SAP eagerly fills. This procedural anarchy fundamentally compromises organizational structure by:
Five Case Studies: What Happens When SAP Replaces SOP
The history of the oil and gas sector is tragically marked by incidents in which weak or missing SOPs enabled the rise of SAP, resulting in disastrous outcomes. There are more out there across different industries.
1. Piper Alpha (North Sea, 1988) — Permit-to-Work & Change Control Breakdown
•What Happened: A cascade of failures, including a faulty permit/lockout-tagout regime and poor shift handover, allowed equipment under maintenance to be restarted. Gas leaked, ignited, and multiple explosions destroyed the platform, killing 167 workers 1.
•SAP vs SOP: Informal communication and workarounds eclipsed a disciplined Permit-to-Work (PTW) and Management of Change (MOC) routine.
•Outcome: The world's worst offshore oil disaster by fatalities, leading to sweeping reforms across the UK Continental Shelf (UKCS) 2.
•SOP Fix to Copy: Rigor in PTW and shift handover, a single “source of truth” for isolations, and MOC that treats modifications and temporary repairs like high-risk work.
2. BP Texas City Refinery (USA, 2005) — Startup Procedure & Siting
•What Happened: During an ISOM unit startup, poor level control and procedural breakdowns overpressurized a tower. Hydrocarbons spewed from an atmospheric vent stack, ignited, and explosions killed 15 and injured approximately 180. The U.S. Chemical Safety Board (CSB) cited a culture of cost-cutting and production pressure 3.
•SAP vs SOP: “Customary” startup practices and production pressure outran written procedures, hazard reviews, and siting rules.
•Outcome: Mass casualties, billions in losses, and industry-wide corrections on startup SOPs and the safe siting of occupied trailers 3.
•SOP Fix to Copy: Start-up “go/no-go” criteria, clear stop rules, independent verification, and siting SOPs that keep people out of blast zones.
3. Deepwater Horizon / Macondo (Gulf of Mexico, 2010) — Procedure Misinterpretation & Testing Discipline
•What Happened: A failed negative pressure test was misread as successful; multiple procedural and management failures preceded the blowout and explosion that killed 11 workers and triggered a historic spill 4.
•SAP vs SOP: Ambiguity and drift in how critical integrity tests were executed and interpreted, often under time pressure, overrode the written intent of well control procedures.
•Outcome: Eleven fatalities and systemic reforms in offshore Safety and Environmental Management Systems (SEMS) and well integrity expectations 5.
•SOP Fix to Copy: Single-point accountability for test interpretation, pre-job briefs with acceptance criteria, and stop-work authority exercised on ambiguous results.
4. Esso Longford Gas Plant (Australia, 1998) — Training & Upset Procedures
•What Happened: Loss of lean oil circulation caused cold embrittlement and a rupture. The resulting fire and escalation killed 2, injured others, and cut gas supply to the state of Victoria for weeks. The Royal Commission cited inadequate training and operating procedures for upsets 6.
•SAP vs SOP: Operators were left to “cope” with abnormal conditions without robust, trained SOPs for upsets and changing feed composition.
•Outcome: Statewide supply disruption and major findings on training, procedures, and MOC, emphasizing the need for procedures that cover abnormal situations.
•SOP Fix to Copy: Abnormal-situation playbooks, drills for upsets, and MOC that treats creeping changes in feed or operating envelope as hazards.
5. PEMEX San Juanico LPG Terminal (Mexico, 1984) — Layout, Isolation & Emergency Systems
•What Happened: A release at an LPG terminal led to fires and multiple Boiling Liquid Expanding Vapor Explosions (BLEVEs). Around 500–600 people were killed, and 5,000–7,000 were injured. Investigations cite poor layout, isolation, and inadequate fire systems 7.
•SAP vs SOP: The “as-operated” reality (spacing, isolation, emergency water) fell far short of a defensible SOP-driven basis of safety. The lack of adherence to safety standards became the de facto practice.
•Outcome: One of the deadliest industrial disasters, providing enduring global lessons on inventory, layout, and emergency response.
•SOP Fix to Copy: Codify minimum separation, emergency isolation, and survivable firewater; treat inventory management and Emergency Shutdown (ESD) logic as non-negotiable SOP.
How to Spot SAP (and Distinguish It from SOP)
Recognizing SAP requires moving beyond a simple compliance mindset and embracing a culture of continuous learning and inquiry. SAP is often hidden in plain sight, and its presence is a clear red flag for organizational structural risk.
SAP Red Flags (What You’ll Hear & See)
•"That manual is old. Here’s how we really do it." (Tribal knowledge is prioritized over the documented procedure).
•Inconsistent Practice: Different shifts do the same job differently; results depend on “who’s on.”
•Permit Failures: Permits are signed after the fact; isolations are not cross-checked; Lockout/Tagout (Lo/To) tags are inconsistent.
•Vague Acceptance Criteria: Startups proceed with no "go/no-go" criteria; acceptance tests are based on "we’ll know when it’s good."
•Temporary Becomes Permanent: Temporary repairs and bypasses that were meant to be short-term become permanent fixtures.
•Near-Miss Normalization: Near-misses are filed as “FYI” with no root-cause follow-up, normalizing the procedural deviation.
•Personal Checklists: Operators carry personal checklists or Post-it notes not reflected in the official SOP, indicating the official document is not fit for purpose.
What Good SOP Looks Like
•Controlled and Clear: Written, version-controlled, and mapped to hazards; roles and responsibilities (RACI) are clear.
•Intent-Driven: Step-by-step tasks include why (intent), not just what (button pushes).
•Explicit Stop Rules: Stop rules and acceptance criteria are explicit (e.g., levels, pressures, test results).
•Integrated Systems: Interfaces to PTW, isolations, Pre-Startup Safety Reviews (PSSR), alarms, and emergency actions are embedded.
•Controlled Deviations: Deviations are controlled via formal processes (temporary change permits + risk review + expiry).
•Trained and Verified: Training and drills are documented; competency is verified; changes go through MOC.
•Auditable: Audits show the field reality matches the page, satisfying regulatory requirements like OSHA Process Safety Management (PSM) and BSEE SEMS/API RP 75 8 9.
Replace SAP with SOP—Without Killing Agility
You don’t beat SAP with bureaucracy; you beat it with clear intent and controlled adaptability. This requires a practical playbook to replace the bad habit of using SAP with robust, living SOPs that still allow for amendments through formal processes.
A Practical Playbook to Eliminate SAP
1. Stand Up an SOP Charter (Safety + Operations Co-Owned): Scope critical tasks (startups, shutdowns, well control, lifting, confined space, hot work, isolations, pigging, chemical handling). Prioritize by risk and consequence.
2. Write SOPs the Way People Actually Work. Then, Elevate: Use field walks and operator interviews. Capture the real sequence, weave in the why (intent), tie steps to hazards and safeguards, and specify go/no-go acceptance criteria. This ensures the SOP is practical and reflects the operational reality.
3. Build “Stop Rules” and “Red Lines”: These are non-negotiable points where work must cease until a condition is met. Examples include: ambiguous negative-pressure test → stop and re-test; PTW missing isolation verification → no work; startup exceeding level/temperature limits → step back. These rules would have changed the trajectory of incidents like Macondo and Texas City 4.
4. Control Deviations (The "Required Room for Amendments"): Instead of pretending deviations don’t happen, control them. Use Temporary Change Permits with risk assessment, time limits, and cleanup tasks (restore, update SOP, train). This is Management of Change (MOC) done right, providing a formal, risk-assessed path for necessary amendments 10.
5. Train, Brief, and Drill: Conduct pre-job briefs with “acceptance criteria & stop rules,” scenario drills for upsets, and competency checks for high-hazard tasks. The Longford Royal Commission was blunt on the consequences of training gaps in abnormal situations 6.
6. Instrument the System: Track leading indicators that expose SAP: permit quality, isolation errors, startup hits/misses, test interpretations, near-miss close-outs, and MOC cycle time trend. This data, by crew and asset, is used to identify where procedural drift is occurring.
7. Close the Loop with Controlled Amendments: Front-line operators should be empowered to propose changes with evidence (photos, trend data). Approvers must test changes on a pilot asset, run a risk review, and then publish SOP vX.Y with training notes and sunset dates for temporary measures. This makes the SOP a living document that adapts to reality in a controlled, safe manner.
Spawn from a Compliance Mindset-Fast Start: a 30-60-90 Plan.
Day 0–30 (Stabilize)
Identify top 10 high-hazard tasks; freeze “work-as-imagined vs work-as-done” gaps with field walks.
Institute stop rules for test interpretations, isolations, and startups.
Move trailers/people out of blast zones where still applicable. Chemical Safety Board
Day 31–60 (Build)
Draft/refresh SOPs with intent + acceptance criteria; embed PTW/isolations and emergency actions.
Stand up a simple MOC + Temporary Change workflow; train supervisors. OSHA
Day 61–90 (Lock-in & Improve)
Drill abnormal scenarios (loss of cooling/lean oil, level instrument failure, kick indicators). qmihsconference.org.au
Launch dashboard for permits, deviations, and near-miss closures.
Publish the first SOP revision pack with redlines and micro-learning.
Compliance Backbone (why this sticks)
OSHA PSM (29 CFR 1910.119) requires written operating procedures, training, MOC, incident investigations, and audits—exactly what turns SOP into muscle memory. OSHA+1
Offshore SEMS (API RP 75; BSEE 30 CFR 250 Subpart S) requires a performance-based system in which procedures, training, MOC, and contractor management work together (on FPSOs, platforms, MODUs, think Guyana’s offshore and GoM alike). American Petroleum Institute+1
K-Thoughts
If your teams say, “That’s not how we really do it,” you don’t have a people problem; you have a system problem. SAP (Standard Arbitrary Practice) thrives in the shadows of thin SOPs. Replacing it with clear, tested, and living SOPs backed by PTW discipline, MOC, and operator-led improvements is the only way to protect people, ensure uptime, and secure the license to operate in the high-hazard world of oil and gas. The cost of procedural discipline is always lower than the cost of a disaster.
Disclaimer: this article was spawned by a real-world scenario observed by the author, and the concepts and methodology presented herein have not been tested. This article aims to raise awareness of what should be obvious. Still, it isn't, and to spark discussions for continuous improvement, better emotional intelligence, and a strong understanding of Skills vs Competency at all levels of any organization.
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