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.