3 SOP Examples That Resulted in Serious Errors

Standard Operating Procedures (SOPs) can help you transfer knowledge in an organization. With this article I will share three SOP examples that resulted in errors with serious consequences – and propose how these failures may have been avoided. 

The first examples of SOPs are found back in the 18^th and 19^th centuries where they supported the industrial revolution. It was pioneers like Frederick Taylor, the father of scientific management in the late 19th and early 20th centuries, that first emphasized breaking down tasks into detailed steps to increase productivity and reduce waste. During World War II, the Allied Forces used SOPs extensively to coordinate large-scale operations, ensuring consistency across diverse units and personnel. After the war, Toyota’s Production System (TPS) in the 1950s incorporated SOP-like methods to ensure continuous improvement (kaizen). 

Today, SOPs are integral to nearly every industry, including healthcare, manufacturing, IT, and food production. They ensure compliance with regulations, improve efficiency, and reduce variability in outcomes. 

However, they don’t always work and then we all need to study the failures and learn how to avoid making them.  

Three SOP examples that failed (with serious consequences)

I have done some research and collected three different SOP examples that failed in their own ways.  

Workers are dying because machines aren’t being turned off

The Wall Street Journal writes about how a 65-year-old worker at a Wisconsin furniture factory was crushed to death in 2020 because the conveyor system was not completely shut down during maintenance. Such incidents highlight the critical need for clear and enforced SOPs to prevent machinery from being inadvertently energized. 

Exclusive | The Preventable Hazard Killing U.S. Factory Workers – WSJ 

This was an error of clarity and specificity: The SOP did not clearly and specifically instruct the worker to close down the conveyor belt before maintaining it. 

How may this have been avoided?

One way is to provide a safety checklist to follow before opening any type of machinery. 
 

Emergency response fails due to ambiguous communication protocols

During cross-organizational emergency responses, unclear SOPs can hinder effective communication and coordination. A study analysing tabletop exercises involving regional first responders in Norway identified challenges stemming from ambiguous SOPs. These unclear procedures led to difficulties in information sharing and decision-making during emergencies, underscoring the necessity for clarity in roles and responsibilities. 
 
https://link.springer.com/article/10.1007/s13753-024-00583-5 

How may this have been avoided?

This is where a swimlane diagram is useful. This type of diagram clearly outlines responsibilities between the departments or roles involved. 

UK Post Office’s Horizon IT Scandal

Hundreds of UK postmasters were accused of fraud or theft due to discrepancies caused by the faulty Horizon IT system. Investigations revealed that the Post Office had not adequately followed procedures to verify the system’s reliability, leading to wrongful convictions and severe personal and financial repercussions for the affected individuals. 

https://www.bbc.com/news/business-50806745?

How may this have been avoided?

The availability of SOPs for system testing in a live setting may have avoided this. In case such SOPs were available then maybe they weren’t easy to find in an organization as large as Royal Mail?  

What makes a great SOP?

So, what can we learn from these errors? The three most important qualities of a useful SOP are: 

Clarity

What it means: The SOP should be written in simple, unambiguous language that is easy to understand by its intended audience. It should avoid jargon unless it’s necessary and familiar to the users. 

Why it matters: If the instructions are unclear or overly complex, users might misinterpret them, leading to errors, inefficiencies, or safety risks. 

How to achieve it:  

• Use clear, concise language and logical step-by-step instructions.

• Incorporate visuals (e.g., diagrams, flowcharts) to enhance understanding.

• Define any technical terms or acronyms used.

Specificity

What it means: The SOP should clearly define who is responsible for each task, what needs to be done, when it should be done, and how it should be executed. It should also account for potential exceptions or contingencies. 

Why it matters: Overgeneralized or vague SOPs fail to provide actionable guidance, leaving room for inconsistent execution. 

How to achieve it:  

• Include precise steps with measurable outcomes (e.g., “Turn off machine by pulling power plug”).

• Clearly state roles and responsibilities.

• Address edge cases or alternate workflows.

Accessibility

What it means: SOPs must be easy to read in the relevant work situation.  

Why It Matters: Even the best SOP is useless if employees cannot easily find and access it when needed. Accessibility ensures compliance and efficiency. 

How to achieve it:  

• Store SOPs in a centralized, user-friendly platform that combines both process flows, roles and work instructions.

• Ensure the platform can be accessed via both mobile device and pc right from the work situation.

Conclusion

Standard Operating Procedures (SOPs) are essential tools for ensuring consistency, safety, and efficiency in organizational processes. However, as the examples in this article demonstrate, poorly written, ambiguous, or inaccessible SOPs can lead to severe consequences, including loss of life, operational failures, and financial and reputational damage. 

By learning from these failures, we can identify the critical elements of effective SOPs: clarity, specificity, and accessibility. When SOPs are thoughtfully crafted and readily available, they become not just a set of instructions but a foundation for safer, more efficient, and more reliable operations. Organizations must prioritize the development and maintenance of high-quality SOPs to prevent errors, save lives, and foster a culture of accountability and excellence. 

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