During a recent discussion with an operations manager at a
chemical plant where we do work, we got to talking about procedures and their
effect on safety. He told us about how they have detailed procedures for their
most dangerous tasks, for example, the loading or unloading of rail cars
containing sulfuric acid. These procedures are designed so that engineers, managers,
and, to the credit of this organization, some employees who actually do the job
identify the correct, one best method to do that job. Once identified the
employees are monitored semi-regularly to ensure that they are following the
procedure, with any variation from the procedure assumed to be unsafe.
The obvious underlying assumption to all of this is that
procedures create safety. Or, to put it another way, if only people did work
the way we planned work to be done there would not be any problems.
But is this true?
Intuitively, yes. We can all cite examples where someone
violated a work rule or a procedure, they got injured, and if they had not
violated the work rule or procedure they would not have been injured.
Therefore, the violation led to the injury. So if a violation leads to an
injury (i.e. a lack of “safety”) then following the procedure must lead to
safety. Therefore, if we want increase safety we need more procedures and more
people following those procedures without deviation.
Seems like sound logic. But there is one problem – this
isn’t the whole picture.
As safety professionals we often get a skewed perspective on
the world. Why? Because we traditionally only focus on failure. And when you
focus on failure you clearly see all of the things that led to that failure
(because of hindsight bias). So, as we said above, we see that someone was
injured (a failure) and we see that one of the proximate causes was a
violation, and we infer the potential effectiveness of procedures as a result.
If we take a step back though, and stop looking at only
failure, and look at success (as recommended by Safety-II), we see
something interesting – violations of procedures most of the time lead to no
injuries. Take driving for example – certainly obeying the traffic laws should
lead to safety on the roads right? But if you go out and just watch people
driving you’ll notice two things – a lot of violations of the traffic laws, and
very few accidents.
Now we’re not saying that we should throw all rules and
procedures out the window and start driving like maniacs. What we are saying
though is that perhaps our belief that the violation of procedures or the
committing of “unsafe acts” being the cause of incidents is misguided. The link
between following procedures and being safe is unproven and, as a result,
suspect. Just because procedural violations are correlated with incidents does
not mean that one causes the other. Correlation does not equal causation.
This sort of begs the question – what does lead to safety?
Well, that’s a very complex question, but the short answer is – people adapting
to their environment. To give an example, in talking with the operations
manager from above we explored the procedure for the railcar unloaders and
identified that the single most important and potentially hazardous step, the
proper way to unbolt the dome of the railcar, is the one that the procedure
spends the least time on. What did the unloaders do? They adapted. They created
informal methods for unbolting the domes based on the type of railcar they were
working with. Essentially, when we looked closer it wasn’t the procedure that
was making the job safe, it was the people who inherently wanted to be safe,
adapting to an unsafe environment and finding the best way, based on the
situation.
- Stop being surprised by procedural violations. There will always be a difference between how we imagine work gets done and how it actually gets done. Our job is to find those gaps and understand why they are there, rather than just blaming workers for not doing things “safely.”
- Stop only looking at why things fail. It gives you a very skewed perspective on the organization that could lead to false assumptions and conclusions. Start looking at why things succeed in your organization and try to enhance that, in addition to looking at and trying to prevent failure.
- If you must write a procedure, have the people who will actually be doing the work write the procedure. You can certainly be involved to ensure regulatory compliance and what not. But don’t assume you know how to do other peoples’ jobs.
- Write procedures in such as way as to maximize their effectiveness, as outlined in this blog here.
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