SafetyInsights.org

This paper applied a worker-centred framework for categorising procedural adaptations, via observing >1.4k procedural steps.

Shared via an open access licence.

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Extracts:

·        “Safety science has developed extensive taxonomies for categorizing human performance failures but lacks equivalent vocabulary for describing successful work performance, leaving practitioners without adequate language to discuss adaptive practices that enable successful work under varying conditions”

·        They developed the Routine-Efficiency-Safety (RES) framework, said to be a “practical vocabulary for Safety-II implementation, enabling organizations to distinguish between different types of procedural adaptations and their functions”

·        “Three distinct categories emerged from convergent evidence: routine adaptations represent normalized workplace practices; efficiency adaptations optimize workflow while maintaining safety standards; and safety adaptations exceed prescribed requirements through additional verification”

·        “The findings support Safety-II principles by demonstrating that workers often possess sophisticated knowledge about effective task performance under varying conditions”

·        “rather than taking shortcuts or minimizing effort, workers often used their experience and expertise to appraise the instructions given to them and understood when and why certain adaptations were appropriate. Workers frequently exceeded procedural requirements through additional verification steps, proactive risk assessments, and redundant safety checks, demonstrating more stringent safety standards than formal procedures specified”

·        “While not all worker adaptations enhance safety, framing deviation from prescribed procedures as errors prevents organizations from learning valuable situated expertise demonstrated in workers’ adaptations”

·        “ procedural flexibility can be a safety feature rather than a problem. The ability to adapt procedures based on situational assessment and risk evaluation represents critical safety capability [36,39] that rigid adherence may limit”

·        “Strict policies on eliminating or penalizing all deviations may serve as a barrier for continuous procedural improvement by limiting the understanding of which adaptations enhance or compromise safety”

·        “Organizations can record and examine adaptation patterns as potential leading indicators of the need for change management”

·        “High frequencies of efficiency adaptations, such as steps being performed out of sequence or combined, might indicate workflow design issues; frequent safety adaptations, such as workers adding protective measures not specified in the procedures, might reveal inadequate risk controls; and variations in routine adaptations, where steps are performed differently than written procedures, might highlight outdated procedures”