If procedural deviation is a primary ’cause’ of failure, what if it’s also a primary ’cause’ of success? (Safe As Quickisodes)

If procedural deviation is a primary ’cause’ of failure, what if it’s also a primary ’cause’ of success?

Today on Safe As Quickisodes, I rapidly unpack a study tracking 1,422 procedural steps across 40 petrochemical operations.

Link in comments.

Using their Skip-Order-Action (SOA) Framework, they explored how frontline personnel navigate written instructions in practice: revealing that roughly 1/3 of steps depart from prescribed methods even when tasks are completed successfully.

We explore how:

a. the SOA framework functions

b. how workers using paper instructions followed fewer steps as the task progressed (e.g. dropping from ~75% adherence to 55%)

c. what these findings mean for safety professionals advancing a Safety-II / HOP approach

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Reference: Ashraf, A. M., Peres, S. C., & Sasangohar, F. (2025). Beyond Compliance: Investigating Work-as-Done in Procedural Work with the Systematic Skip-Order-Action (SOA) Framework.