Why do people bend the rules, deliberately fail to follow procedures? There is an assumption that people will follow the guidelines and procedures as laid down in the Safety Management System. When this assumption is broken the whole basis of the Safety Management System is temporarily put at risk. The main reasons for violation are: 1. Expectation that the rules will have to be bent to get the work done; 2. Powerfulness, the feeling that one has the ability and experience to do the job without slavishly following the procedures; 3. Seeing the Opportunities that present themselves for short cuts or to do things `better'; 4. Inadequate Work Planning and advance preparation, leading to working 'on the fly' and solving problems as they arise. This manual provides two ways to combat violation, proactive and reactive. * The reactive approach involves finding out what rules are being broken and fixing the reasons why that is happening. * The proactive approach concentrates upon finding out whether the scene is set for violations, even if they are not happening right now, and ensuring that problems don't arise. Because most people do not find themselves breaking the rules that frequently, it is often better to concentrate upon the proactive approach. The recommended remedies for violation problems are: * Supervision - watch more closely over people, plan their work, provide an example * Analysis of existing violations - find the background behind violation behaviour * Analysis of violation potential - use the theory to see if people will find violating easy * Structured discussions - discover what is going on and get people to agree on actions * Procedures - improve the quality of procedures so violation is not seen as necessary * Direct management - a technique to vary the procedures as circumstances demand * A Diagnosis-Remedy matrix is provided showing which approaches are effective and what side-effects may be expected. Part I of this manual starts with a simple description of the problem and the solutions proposed. The diagnosis-remedy matrix forms part of this brief overview. The remainder of the manual is optional, written for people who want to go further. Readers intending to apply the diagnosis and remedy techniques are recommended to read those sections. Part II provides a more detailed introduction to the theory for understanding violation and the proposed remedies. Part III documents the proactive approach. Part IV documents the reactive approach. The knowledge in this manual is based upon field studies carried out by Leiden and Manchester Universities for Shell International Exploration and Production (SIEP), in co-operation with NAM and Expro. In this study a theory was developed to understand deliberate failures to follow procedures. The theory has been tested on offshore operators, supervisors and contractors in the North Sea and found to be accurate to predicting more than 2/3rds of violating behaviour.
Samenvatting