SafetyInsights.org

This study explored the use of safety-critical procedures in maritime transport. Interviews, observations and document reviews were included in the methodology.

Before moving into the findings, the authors provide a nice overview of ideas around procedures and the perception of procedures. One line of research they cover argues that procedures aren’t just strict if-then scripts to control behaviour but are rather resources for action which help guide decisions and behaviour. Thus, it’s not a simple black and white process for people to operationalise them.

Further, previous researchers have criticised the idea that procedure use can be separated independently from the social situations, since work “has to be seen as situated actions, i.e., an integrated process of actions and interpretations within a specific social context” (p2).

Finally, the use of terms like violation or deviation aren’t objective but also carry with them value judgements which can bias discussions. Unfortunately this isn’t covered too much in the paper.

Results:

First, the ‘usual’ findings were observed where a large number of people (67%) routinely did not follow procedures. Reasons were the number and poor quality of procedures; over-detailed or over-specified; schedule pressures; not relevant or written by seafarers & seen as legal back-covering. It was said that “the company’s demands for efficiency meant that they sometimes violated the procedures” (p.6).

Notably, several departures were observed to improve process efficiency – and in some cases, to improve safety. In some cases the workers weren’t aware they were departing from procedural process.

Too many procedures were seen to devalue the technical competence of people, where seamanship and individual skills helped maintain safe performance. Further to this, other research was cited that emphasised the disparity between the paperwork used in maritime versus established practice. However, some procedures were seen to be useful, mainly for emergency situations; checklists for high-risk work; & training new staff.

Masters reported departing from rules more regularly than lower seamen. There was also a perception by some that procedures were used to blame people and this therefore resulted in a level of antagonism towards procedures.

What I found interesting is the findings relating to the Safety Management System (SMS). Besides being poorly understood or too dense – it lacked internal consistency. Documents were classified as instructions, procedures or system descriptions, but some instructions were also referred to as procedures. Many procedures were actually system descriptions without any rules or instructions. Some procedures only referred to other procedures and contained little to no new information. To me this aligns with research on clutter.

Further breaking down ‘procedures’, only 5% of these had action rules (describing step-by-step of what to do), and only 10% were process rules (describing what should be done but not how to do it).

The term “procedures” was often used by crew to denote every document in the SMS. In some cases, every document contained within the management binder was called a procedure. The SMS was believed to contribute to procedural deviation. Although most respondents indicated that their company had an orderly management system, demonstrated according to the workers by the “voluminous library of binders in the office”, it’s said that the “actual knowledge regarding the content among the seafarers, however, seemed to be rather limited” (p7).

Also of interest, but not at all surprising, is where the authors discuss how procedural violation taxonomies (such as that from James Reason) may not sufficiently capture the complex interrelationships contributing to deviations. For example, in decisions leading to goal conflicts the existing taxonomy can be ill-suited to describe these situations.

E.g. to quote “It is not always straightforward, or even possible, to classify violations into one single discrete category within a certain violation taxonomy. The incentive for some violations seems to be somewhat complex in nature and related to a diversity of contextual condition embedded in the organisation” (p.9).

Authors: Rolf Johan Bye, Asbjørn Lein Aalberg, 2020, Safety Science

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Study link: https://doi.org/10.1016/j.ssci.2019.104538

Link to the LinkedIn article: https://www.linkedin.com/pulse/why-do-violate-procedures-exploratory-study-within-ben-hutchinson