Violation of OSH rules and procedures

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Lauren Clignett, Jakko van Kampen, TNO

Introduction

Although estimates vary, it is widely accepted that human error plays a part in most safety accidents and incidents [1]. Human error could be coupled with the active failures at the front-end and the actions or inactions of managers and engineers, the latent failures. This OSH wiki deals with a specific form of human error: violations of OSH rules and procedures. To understand violations we place violation in the larger framework of human error, explain which type of violations exist, delve into the root causes or reasons for violation and discuss effective strategies to mitigate the negative consequences of violations.

Frameworks for human error

Most if not all accidents include in part human actions or inactions as a contributing factor. Either in the execution of work (e.g. someone pushing the wrong button), the preparation of work (e.g. poor planning) or for example in the quality of design and/or maintenance of equipment.

To control human error, two paradigms can be identified in the literature, a top-down approach and a bottom-up approach. In order to control human errors most modern companies have created extensive procedural frameworks, like safety management systems (see OSHwiki safety management system) which are also meant to describe and regulate undesired behaviours of employees. Rule violation occurs when these organisationally, professionally or legally defined rules are not followed by employees. When companies take a top-down approach all violations are unacceptable [2]. Violations are considered to undermine the control the organisation thinks it has over its OSH risks through the safety management system. The idea is that if all employees work according to the rules risks will be mitigated. The root cause to violation is therefore attributed to a poor OSH culture (see OSHwiki OSH culture).

There are also companies in which a bottom-up approach is followed, where experience and expertise are considered most relevant for which informal ‘procedures’ to follow [2]. In practice a combination of approaches will be present in most companies. In order to understand and improve upon rule violation it is crucial to start from an understanding of human error and human performance in general (see OSH wiki on Human Error). An influential taxonomy of types of human error was proposed by Rasmussen [3]. His taxonomy was based on cognitive psychological research in which a distinction is made between three modes of operating and their respective types of error:

Table1level.PNG

Source: Rasmussen [3]

Reason [1] in his influential book “human error” associated each type of performance with a particular type of error in his GEMS (Generic Error Modelling Systems).

Table2generic.PNG

Source: Reason [1].

On the basis of these works further taxonomies of human error were developed such as those by the US Department of Defense (HFACS) [4] and the UK Health and Safety Executive [5]. In these taxonomies, which are broadly similar, violations are included next to human error. See Figure 1 below for the HSE framework for human error.

Fig1Hse.PNG

Source: Health and Safety Executive 1999[5]


Violations

Though the above-mentioned taxonomies are broadly similar there are some differences with respect to the classification of violations. As can be seen in the table below:

Table3description.PNG

Source: Reason[1], Hudson, Parker & Lawton[6], Health and Safety Executive [5], HFACS [4]

Unintentional violations

Hudson [6] defines a category of unintentional violations. These occur when rules are written “in an attempt to control behaviour that is impossible to control” or when employees do not know or understand the rules that they are expected to follow. It can be argued that these types of violations should be viewed as errors rather than violations. The category does help point out the role of intentionality. It is obvious that unintentional violations are very likely to require different remedial actions than those appropriate for intentional violations. An example of an unintentional violation would be the violation of the rule posed by the British Highway Code: “do not slip or remain in control of your vehicle at all times” [6].

Acts of sabotage

Reason[1] defines ‘acts of sabotage’ as a form of violation. Though acts of sabotage may occur, the management of this behaviour is outside the scope of this article.

Routine violations

Routine violations are identified in all classification models. Routine violations occur when the normal most common ways of working are different from prescribed rules and procedures. Often routine violations are so common amongst a group of employees that they are no longer perceived as violations or deemed to be risky behaviour. DODHFACS [4] further defines violations based on risk assessment, these are generally routine violations but accompanied by a risk assessment sanctioned by leadership. For example the inquiry into the Clapham Rail Crash revealed that routine violations played an important role. Maintenance working practices had been degraded over time in such a way that the prescribed methods for these tasks where routinely violated. This was also due to lack of supervision and training, allowing the situation to persist [5].

Situational violations

Situational violations are identified by Reason[1], Hudson et al [6] and the HSE [5]. Situational violations occur when circumstances in the workplace (such as time pressure, equipment availability) require or entice employees to violate specific rules. For example an employee was killed falling whilst erecting a steel structure. The employee had needed to climb a structure but there was no provision for securing him with a harness and no other safeguards where available [5].

Exceptional violations

Exceptional violations occur in unusual circumstances for example in crisis situations and might in those cases even be inevitable. It is then believed that violation is necessary to cope with the exceptional circumstances. As an example the inquiry into the accident at the Chernobyl nuclear power plant revealed that during testing before the accident an anomaly occurred. Operators and engineers continued to improvise to protect their test plan leading to an increasingly unstable power plant [5].

Optimising violations/lack of discipline

Optimising violations are only identified by Hudson and colleagues [6] and seems to be similar to the lack of discipline violations identified by HFACS [4]. They occur when employees are tempted to cut corners and finish work early, seemingly acting in their own interest.

In Reason’s [1] model all violations are assumed to be an intentional deviation from OSH rules of procedures (otherwise they are considered a slip, lapse or mistake). The idea behind violation is that OSH rules and procedure will prevent incidents. It can however also be the case that not following procedures leads to a safer outcome. For example in exceptional circumstances: The men on Piper Alpha who jumped off the platform ended up violating emergency procedures and survived, but those who did follow procedures ended up dead [6].

Why do people violate?

The different types of violations have been explained, but this does not explain the reasons why people violate. Hudson et al. [6] describes in his Behavioural Cause model the four main contributing factors to violation (the lethal cocktail):

  1. Expectation that rules have to be broken
  2. Powerfulness of competence to work around procedures
  3. Existence of the opportunity to violate
  4. Inadequate work planning.

In a review by Alper and Karsh [7] an overview of findings in the research was summarised. In this overview potential and proven reasons for violating procedures were subdivided into individual, organisational, rule related and hardware factors.

Table4Organisational.PNG

Source: Found by Alper and Karsch [7], summarised by Hale and Borys[2]

Table5Individual.PNG

Source: Found by Alper and Karsch[7], summarised by Hale and Borys[2]

In these tables 4,5 shown above the main results from the review conducted by Alper and Karsch [7] are shown as summarised by Hale and Borys [2]. These are grouped in individual, hardware/activity, organisational/safety climate factors or rule related factors. The factors identified by Alper and Kirsch [7] should be seen as examples of underlying causes for violation. In many frameworks (e.g. Groeneweg [8], Reason [1], HFACS [4]) these are termed preconditions or latent failure.

Hudson [6] also defines sheep and wolves for attributing violation potential to personal attributes. Sheep are the guardians of high standards and unlikely to break rules. However if procedures fail or better, more efficient, but still safe ways of working exists, the opportunistic go getting characteristics of wolves helps organisations to innovate and improve their processes. Theory predicts that removing the causes of violations would be more effective then removing the violators. In the approaches to reduce violations the focus is therefore on different type of violations rather than different types of violators.

Approaches to reduce violations

Violation is given limited attention in EU legislation, directives and guidance. What can be found is mostly related to sanctioning violations with individual and organisational fines. This purely regulatory approach is unlikely to fully address the diverse causes of violations that are identified in the literature and is as such unlikely to reduce violations (completely).

It is often found that violations are combated mostly or even exclusively by reiterating the rules and procedures that are applicable [9]. In any organisation with even moderately complex work processes it is practically impossible to capture all possible situations and circumstances in rules and regulations (see also [1]). Control through experience and skill is still necessary. Rules may not apply under all circumstances; as such it is possible for rule violation to contribute to safety in specific circumstances. When observing the underlying causes for violations it is unlikely that merely reiterating a rule will influence the frequency of many violations. For example when violations are necessary to compensate for poor equipment or when management turns a blind eye to violations (see table 3).

In this article two main approaches to reduce violations will be discussed, the individual and organisational approaches.

  1. Individual approaches are focused more on the individual or individuals that violate rules and generally include behavioural based safety and/or leadership programmes.
  2. Organisational approaches are focused more on circumstances and organisational factors that contribute to or reduce the occurrence of violations. By removing external triggers and optimising the organisational and technical circumstances the frequency of violation can be reduced.

It should be noted that specific interventions often comprise of a mixture of these two approaches. In individual approaches for example the social and organisational context can be part of the intervention, but it is not the main focus of change. Similarly in an organisational approach attention is paid to individual behaviour but interventions are more aimed at optimising circumstances and triggers.

Reducing violation with individual approaches

Within an individual approach an attempt is made to influence individuals and for example train them to reduce violation. The social and organisational context is usually part, but not the main focus of change. Notable examples of these approaches are behavioural based safety programmes and leadership programmes.

There are numerous behavioural based safety programmes which are used throughout industry. These programmes typically consist of structured observations which are conducted on the shop floor. Safe and unsafe behaviours are made explicit and actively managed through observation and feedback. Observers are trained to conduct walk rounds, observe behaviours and give direct feedback to workers when unwanted behaviour is observed. According to Cooper [10] the components of an ideal behaviour based safety programme include:

The components of an ideal process are:

  • Identify unsafe behaviours (obtained from injury and near-hit incident records).
  • Develop appropriate observation checklists (which feature behaviours implicated in injuries).
  • Educate everyone. Tell and sell to all, and train observers, facilitators and champions.
  • Assess on-going safety behaviour by conducting behavioural observations.
  • Provide limitless feedback—verbal, graphical and written—on results.

There are also many leadership programmes actively promoting compliance to rules and procedures and promoting the development of leadership skills. Typically they involve the assessment of personal safety norms and the development of leadership and communication skills in line management. Compliance is promoted through visible leadership, role-model behaviour and not tolerating violations of procedures. As part of this, employers must have a robust and effective system in place for disciplining those who carry out such violations. In addition leaders can be taught to influence the organisational environment within their organisations, for example by actively searching and removing organisational causes for violations (e.g. time pressure, poor planning).

Reducing violation with organisational approaches

In addition to the individual approach there are also organisational approaches to reduce violations. In an organisational approach the management system or technical and social environment are considered central for reducing violations. There are many frameworks that can be used to conceptualise, analyse and intervene with respect to organisational factors relevant for violation. In this section we will discuss two approaches.

Hale and Borys [9] argue that violation is due to perceived quality of procedures by shop-floor employees. The primary objective is to reduce violation by rule management. They propose a framework to improve rule management within organisations:

  1. Monitor the use of existing rules
  2. Evaluate the rules for their effectiveness
  3. Enforce the use of good rules
  4. Execute rules and deal with exceptions
  5. Redesign or scrap ineffective rules
  6. Define the rule for new processes or existing process
    1. Define the processes, risk scenarios and controls
    2. Decide which controls need rules to be developed
    3. Define use of the needed rules
  7. Develop and write appropriate rules
  8. Test and approve rules and store in organisational memory
  9. Communicate and train in rule use and adaptation

Based upon the notion of latent failures [1], Groeneweg [8] defined eleven organisational risk factors within organisations that can be influenced by the management and which were found to play an important role in the occurrence of human errors and accidents. These organisational risk factors create the circumstances on the shop floor that can lead to violations The eleven basic risk factors are:

  1. Design: workplace design, layout
  2. Training: education and training for optimum work performance
  3. Hardware, materials and resources: machines, tools, installations
  4. Communication: the quality of written and verbal communication
  5. Maintenance management: the systematic scheduling and performance of maintenance
  6. Incompatible goals: the relative importance of safety compared to other priorities, such as productivity and cost management
  7. Housekeeping: storage/waste facilities
  8. Organisation: the quality of the organisational structure
  9. Error enforcing conditions, ambivalent factors: relevant external factors: heat, cold, stench, but also motivation, boredom, macho behaviour, etc.
  10. Defences, protection: the manner in which people are protected against dangerous situations, e.g. personal protective equipment, first aid

Procedures: the quality and efficiency of work requirements and procedures.

Effectiveness of approaches

There is limited systematic research on the effectiveness of various approaches to actually reduce violations and more importantly to improve safety outcomes. There are, however, some sources available.

The Health and Safety Executive [11] for example specifically looked at approaches relevant to each violation type, excluding the unintentional violation type and found:

  1. Routine violations can be minimised by assessing risk, reducing risk-taking, increasing the probability of detection and reducing the number of unnecessary rules
  2. Situational violations can be minimised by improved job design, planning, hazard reporting system, working conditions, positive health and safety climate and appropriate supervision
  3. Exceptional violations can be minimised by increased training for unusual situations, reduce pressure, time pressure and put defences in place
  4. Optimising violations can be reduced by job redesign and examination of restrictive rules.

Hudson [6] distinguishes between Division I and Division II remedies and considers the following approaches effective or ineffective:

Table6division.PNG

Source: Hudson[6]

In general research suggests that the social and environmental factors are more important in predicting the occurrence of violations then individual level factors (Groeneweg[8]; Bates and Holroyd [12]; Alper and Karsch[7]; Hale and Borys [9].It can therefore be expected that approaches which include an organisational approach would be more effective at reducing violations. It is clear from the available studies that the causes of violations are multifactorial and complex. Therefore for all types of violations a combination of individual and organisational approaches is recommended. More research into the effectiveness of various approaches could provide further insight.

Whistleblowing[13]

Although internationally and in some individual MSs protection exists for those who are whistleblowers (i.e. they report wrong doing which, for example, places someone's health or safety in danger) there are no EU-wide provisions in place. This was recognised by the EU Parliamentary Assembly (2010) in recording that "Most member states of the Council of Europe have no comprehensive laws for the protection of whistle-blowers"[14] Although an issue that extends beyond that of health and safety in the workplace, workers should be encouraged to report significant breaches of occupational health and safety and should not fear any reprisals for doing so. For example, a Luxembourg law relating to the fight against corruption states that ‘an employer is not authorised to retaliate against the person who has filed a complaint or informed the employer of any wrongdoing’[13].

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Reason, J., Human error, Cambridge University Press, 1990.
  2. 2.0 2.1 2.2 2.3 2.4 Hale, A., and Borys, D., Working to rule, or working safely? Part 1: A state of the art review, Safety Science, 2013, 55, 207-221
  3. 3.0 3.1 Rasmussen, J. Human error. A taxonomy for describing human malfunction in industrial installations, Journal of Occupational Accidents, 1982, 4, p. 311.
  4. 4.0 4.1 4.2 4.3 4.4 Shappell, S.A., Wiegmann, D.A. The Human Factors Analysis and Classification System–HFACS, 2000. DOT/FAA/AM-00/7 U.S. Office of Aviation Medicine. Washington, DC 2059. [1]
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Health and Safety Executive. HSG 48 Reducing Error and Influencing Behaviour, 1999. [2]
  6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 6.9 Hudson, P.T.W., W.L.G. Verschuur, D. Parker, R. Lawton and G. van der Graaf. ‘Bending the Rules: Managing Violation in the Workplace’, 1998. Invited keynote address, Society of Petroleum Engineers International Conference.
  7. 7.0 7.1 7.2 7.3 7.4 7.5 Alper, S.J., Karsh, B. A systematic review of safety violations in industry, Accident Analysis and Prevention, 2009, 41, 739-754.
  8. 8.0 8.1 8.2 Groeneweg, J. Controlling the controllable: the management of safety, 1998. DSWO Press. Leiden. 4th edition.
  9. 9.0 9.1 9.2 Hale, A., Borys, D. Working to rule or working safely? Part 2: The management of safety rules and procedures, Safety Science, 2013, 55, 222-231
  10. Cooper, M.D. Behavioral Safety Interventions A review of process design factors, 2009. Professional safety.
  11. Health and Safety Executive. Improving compliance with safety procedures reducing industrial violations, 1995. [3]
  12. Bates, S. Holroyd, J. Human factors that lead to non-compliance with standard operating procedures, 2012. Health and Safety Laboratory, Harpur Hill, Buxton, Derbyshire.
  13. 13.0 13.1 EurWORK, European Observatory of Working Life, New developments in the protection of whistle-blowers in the workplace. Published on 19 August 2016. Accessed 29 May 2017. https://www.eurofound.europa.eu/observatories/eurwork/articles/law-and-regulation/new-developments-in-the-protection-of-whistle-blowers-in-the-workplace
  14. Parliamentary Assembly Resolution 1729 (2010) Final version. Protection of “whistle-blowers” http://assembly.coe.int/nw/xml/XRef/Xref-XML2HTML-en.asp?fileid=17851&lang=en

Link for further reading

Some examples of behaviour based safety and leadership/culture approaches include: The DuPont STOP program, [4]

BST Solutions’ program, available at: [5]

The Hearts and Mind Culture programme, available at: [6]

The Keil Centre Safety Culture Maturity® Model , [7]

HSE Human Factors Briefing Note No. 7 on safety culture, [8]

The ELMERI safety observation approach, [9]

Some examples of organisational optimisation approaches include: Managing rule breaking,[10]

Tripod Delta, [11]