Dear User,

This presentation has been designed for you by the Hearts and Minds Support Team

It provides a guideline for conducting a Managing Rule Breaking workshop

The presentation has been supplied with speaker notes and has been checked for correctness and relevance

Please note that all the examples have been chosen to support people from all industries

Please, feel free to replace them with your own examples and/or add any slides and exercises you find useful

We hope you will find it useful

Best regards,

The Hearts and Minds Support Team

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Managing Rule Breaking

Managing Rule Breaking

WHATA simple tool that explains why people break rules

WHYTo help establish a culture of compliance and working safely that will assist in achieving Goal Zero

HOWBy helping to understand why people break rules and how to manage and change this behaviour

The Swiss Cheese Model

Why break the rules?

Wolves and Sheep

Do not accept

violations 34%

Wolves in

Sheep Clothing

22%

Sheep

14%

Sheep in

Wolves’ Clothing

30%

Wolves Accept

Violations

Never Violate Violate

OPTIONALSLIDE

Types of Rule Breaking: Errors

SlipsDoing something one did not mean to “You decide to stop adding sugar to your coffee and then find yourself doing it anyway ”

Lapses Forget to carry out an action“You are on your way to work when the thought strikes you: Did I lock the door?”

MistakesThe chosen plan was wrong“The doctor makes a wrong diagnosis and as a result prescribes the wrong medicine”

Types of Rule Breaking: ViolationsUnintentional Incorrect/unclear rules or faulty communication and training

“Because they did not know the procedures operators were not using correct PPE”

SituationalImpossible to do the job without breaking the rules due to lack of resources

“A technician discovered that the tool they were supposed to use does not fit in the space available. They used a different tool instead”

OptimisingMore convenient, profitable, pleasing the boss, fun

• Organisational: For the benefit of the organisation/boss“Not to cause any production losses a maintenance worker decides to fix a broken relay without turning off the electricity supply”

• Personal: For the benefit of the individual “In order to get home in time a person is driving 70 km/h where the speed limit is 50 km/h”

Types of Rule Breaking: Special Violations

Reckless Optimising ViolationA rule was violated without thinking or caring about the consequences “Drunk Driving”

RoutineAny violation that has become the normal way of doing things“Crossing the street on the red light whenever there are

no cars”

Exceptional Novel, extreme situations for which there is no guidance “A man dies while trying to save a child”

When a hazard is presentViolation + Error = DISASTER

Examples

Violation: Someone walks behind a truck without informing the driverMistake: Believing it is safe, the driver selects reverse gearResult: The driver runs the person over

Violation: A driver is not wearing their seatbelt Error: A driver takes a bend too quickly on a slippery road Result: The vehicle rolls over

Violation: A driver on the outside lane is speedingError: A driver on the inside lane forgets to look in the mirror when switching lanes Result: Collision

How Do You Know

Was therebehaviour belowexpectations?

Did theperson’sactions deviatefrom what theyintended?

Did the personmake anincorrectdecision or wastheir work planinadequate?

Did the personviolate becausethey did notunderstand orwere unawareof the rule?

Did the personviolatingbelieve the jobcould not bedone if theyfollowed theprocedures?

Did the personviolating think itwas better for thecompany to do itthat way? Or, werethey trying toplease the boss?

Did the personviolating thinkit was better forthempersonally todo it that way?

Did the personviolating mean todo what they didand did not thinkor care about theconsequences?

Slip or lapse Mistake Recklessviolation

OrganizationalOptimizingViolation

Unintentionalviolation

Situationalviolation

PersonalOptimizingViolation

Human Error and Violation Decision Flow Chart

YES

YES YES YES YES YESYES YES

NO NO NO NO NO NO

If others do it the same way:

Routine Violation- same violations

by different people

Routine Violation -personal history of

violations.

If this has happened before:

Routine Error -personal history of

errors.

Routine Error -same errors bydifferent people

If this person has a history of personalviolations:

Errors Organizational Issues Personal Issues

Routine

Reward Coaching Formal Discipline

“In order to avoid production losses and start work on time, it has become common practice to skip an important but lengthy check”

Procedures and Practices Questionnaire

Individually:Complete the Procedures and Practices Questionnaire

In Groups:Compute the group average for each violation types

• If the average is less than a ‘critical score’ discuss that type of rule breaking

• If several areas are identified, focus on Exceptional Violations last

• If routine violations are identified

• What was the original violation type?

DiscussionDiscuss your scores with the group:

• Is there a certain type of rule breaking that might be an issue?

• Which category is it?• What type of problem does it

cause?• Why?• Is there specific rule or

procedure causing it?

Do you have any own examples?What were the specific problems there?

Reasons for No Procedures

Procedures may cause problems as they:•Become more complex over time•Are written with unrealistic assumptions•Often are an overly simplistic solution to a hard problem•Their level does not match the user

OPTIONALSLIDE

Reasons for Procedures

•Complicated jobs•Long instructions•Non-obvious safety checks and standards•Information for safe and effective operation•Define the steps order when alternative sequences are

possible•Define common work practices•Ensure everyone “plays the same game”•Information transfer as new people arrive

OPTIONALSLIDE

Writing a Good Procedure

•Involve your team in a process •Review what happens in practice •Remember: people make mistakes•Define the end-user•Check HSE requirements•Identify critical sequence activities•Place memory aids•Try it out•Define review criteria •Update on regular bases

OPTIONALSLIDE

Writing Good Procedures

Use short sentencesUse active voiceBe direct

Tell the reader what to doUse short words (“Raise” instead of “elevate”)Do not use abbreviations or acronymsBe consistent with terminologyDo not assume the reader knows somethingPut steps in the right sequence

OPTIONALSLIDE

Improving Safety By Improving Procedures

•Are the existing procedures • Correct?• Available?• Understandable?• Actually understood?

•Are there any unnecessary ones you could get rid of?•Do resources and circumstances allow rule-following?•Is rule following rewarding?•Do people feel comfortable to use their initiative without

risks?•Is the improvement progress reviewed regularly?

OPTIONALSLIDE

Group Debate

EXAMPLE: SPECIFIC PROCEDUREWhat is its purpose and which hazards does it control?Do we need it?

• What are the consequences of removal?• Are all the hazards still under control?• What if the removal is not possible?

Creating ComplianceDiscussion

How can we be more compliant?Compliance through consequences

Reward or PunishmentGroup Pressure

What hazards are being managed?What type of accidents could take place?What are the advantages of non-compliance?Is it worth the risk?Will individuals comply if enforced by the group?Are there alternatives to compliance? How will the group ensure compliance?How does a group create compliance?

Forcing FunctionsIs there a way of ensuring compliance by creating a situation in which there is no opportunity to violate?

OPTIONALSLIDE

Creating Compliance

Rewards and Punishment

Rewards and recognition• Takes time to work• Rewards need to be given close in time to the behaviour being

rewarded• Often small non-material rewards work best• Personal praise and recognition is particularly effective Punishment• Effective in the short term• Problem: people are likely to change their behaviour to avoid

punishment rather than to act safely• Must be seen as just and fair

Creating Compliance

OPTIONALSLIDE

Group Pressure and Forcing Functions

Group pressureThrough competition between groups or using group rewards• Only works if people want to be part of the group• To be effective, group needs to last at least six months• To be effective, group should contain some people already doing

the right thing

Forcing functionsWays to force behaviour • A vehicle will not start unless the seat belt is used• The mobile phone on/off switch is connected to the handbrake

circuit (brake off, phone off)• You can only start shift during the tool-box talk

Creating Compliance

OPTIONALSLIDE

Action PlanHow can we be more

compliant?What are you going to do?Who will do it?When will it be done?Who and when will review it?

Is your Action Plan SMART:Specific?Measurable?Achievable?Realistic?Time based?

Action PlanACTION

What are we going to do?

Who will do it?

When will it be done?

Who will review it?

When will the review take place?

Action PlanACTION

What are we going to do?

Who will do it?

When will it be done?

Who will review it?

When will the review take place?

Questions

Backup Slides

Examples of violations

An Unintentional Violation

Example of poor procedure/instruction:

PR 1508 LIFTING TUBULARSThe slings should be doubled wrapped with a choke hitch taking care not to cross over the sling on the underside of the pipe or pipe bundle. The choke hitch should be pulled tight to secure the bundle and a bulldog grip fitted. A tie wrap should then be fitted to prevent the reeving eye slipping over the bulldog. The included angle between the choke hitches shall not exceed 120 degrees

Vehicle wheel clamped for

violation

Clearly on obstruction

here and no parking

It is OK here… or

not?

Another Unintentional (Routine) Violation

Types of Rule-Breaking: A Situational Violation

It is sometimes impossible to get the job done while following the rules

A steel worker was killed when they fell 20 m from a structure under construction. After investigation it occurred that even though harnesses were provided there was no provision for fixing the broken ones and there were no other safeguards available. As the workers were afraid of losing their jobs if they refused to work, they kept on using the broken harnesses while fulfilling their tasks.

A Personal Routine ViolationRules are broken in order to reach a personal goal. Additionally, everyone involved feels the rules are irrelevant and they no longer appreciate the dangers of the situation

Everyone does it like that!

Personal Optimising ViolationRules are broken in order to reach a personal goal

Because they were in a hurry to get home early, instead of asking for a scaffold, a construction worker used their own ladder to tighten a screw at 5 m height.

Organisational Optimising Violation

Done with the intention of achieving organisational goals. Getting the job done faster, cheaper etc

During the conceptual design of a project, a number of environmental considerations are dropped in order to reduce costs and speed up the work

Reckless Violation

A rule was violated without thinking or caring about the consequences

A fuel tanker driver knows that lack of attention can cause an accident, possibly resulting in an explosion, but still uses a mobile phone while driving at high speed on a busy highway.

When your friend is overcome by H2S the human reaction is to want to help them, whereas the rule (correctly) says leave them and get help. Often the first person survives but those who try and help without BA usually die

When attacked by a bear lie down in front of it and keep very still and quiet (unless it is a black bear, in which case screaming seems to work best)

During the Piper Alpha incident, a couple of the crew decided to leave the mustering area whereas most of the crew stayed-put (the rule said so). Those who made the former choice, survived

Exceptional Violation

Low Cost Motivators17. Thank somebody that contributes ideas,

regardless on whether you use it

18. Always give others credit when due

19. Create group awards to recognise teamwork

20. Ask the employees how they want to be

recognised

21. Ask a superior to write a memo acknowledging an

accomplishment for your employee

22. Post complimentary letters on the safety bulletin

board

23. Send employees to special seminars and

workshops that may interest them

24. Safety Day

25. Safety Olympics

26. Safety T-Shirts

27. Dinner for two gift

28. Certificates

29. Weekend stay at bed & breakfast

1. Write a letter of commendation

2. Ask employees for advice/opinions

3. Give verbal praise

4. Pass along compliments you received from others

5. Write an e-mail/memo to a superior and cc the

employee

6. Put positive information in the employee’s

productivity file

7. Provide quick follow up on problems/hazards when

recognised

8. Post positive achievements on the safety bulletin

board

9. Say “Thank You” and mean it

10. Allow flextime

11. Designate special parking places

12. Give out award plaques, trophies or diplomas

13. Feature an employee of the month

14. Recognise peers that have helped you

15. Have a coffee/juice morning to acknowledge

accomplishments

Three Levels of ProceduresRules and Guidelines

• Define acceptable operating standards• Define Good Practice• Assume a level of operator competence

Work Descriptions• Operate within Guidelines• Describe advisory steps, actions and sequences• Require co-ordination with more people

Work Instructions• Step by step requirements• For use in critical or complex situations• Defined for operators with lower basic competencies• Often required legally

Safety Improvement • Remove Procedures • Rewrite Procedures • Job Redesign

• Job enlargement• Job enrichment • Flexible working groups, including job rotation

• Workforce Involvement • Variance Permits • Enforcement

Managing ViolationsType of violation

Main cause Main solutions

Unintentional Violation – Understanding

Complexity Poor documentationFailure to consider end users

Reduce and simplify rulesRewrite procedures and rulesInvolve users in their development

Unintentional Violation – Awareness

Poor trainingRules not available

Better communication and training Rules/standards available in local language

Situational Violation

Lack of resourcesFailure to understand working conditions

Provide necessary resources and equipmentProvide flexibility and variance in procedures to meet all likely situations

Exceptional Violation

Unexpected situations – no obvious rulesPressure to solve problems

Train for the unexpected Develop situation awareness skillsAcquire general problem solving skillsSee other Hearts and Minds Tools modules

Managing ViolationsType of violation

Main cause Main solutions

Unintentional Violation – Understanding

Complexity Poor documentationFailure to consider end users

Reduce and simplify rulesRewrite procedures and rulesInvolve users in their development

Unintentional Violation – Awareness

Poor trainingRules not available

Better communication and training Rules/standards available in local language

Situational Violation

Lack of resourcesFailure to understand working conditions

Provide necessary resources and equipmentProvide flexibility and variance in procedures to meet all likely situations

Exceptional Violation

Unexpected situations – no obvious rulesPressure to solve problems

Train for the unexpected Develop situation awareness skillsAcquire general problem solving skillsSee other Hearts and Minds Tools modules

Managing ViolationsType of violation

Main cause Main solutions

Organisational Optimising Violation

Pressure from others Understand causes of pressureManagement to set clear expectationsIntervene in a consistent mannerApply clear consequences (positive and negative) to both the individual and the supervisor/ managerMake rules easier to followImprove competence

Personal optimising

Personal convenience

Routine Unnecessary rulesPoor attitude to complianceWeak supervision

Remove rules (but still control the hazard)Improve attitudes to rule breakingAddress the type of violation that has become routineApply clear consequences for individuals and their managersImprove intervention skills

Managing ViolationsType of violation

Main cause Main solutions

Organisational Optimising Violation

Pressure from others Understand causes of pressureManagement to set clear expectationsIntervene in a consistent mannerApply clear consequences (positive and negative) to both the individual and the supervisor/ managerMake rules easier to followImprove competence

Personal optimising

Personal convenience

Routine Unnecessary rulesPoor attitude to complianceWeak supervision

Remove rules (but still control the hazard)Improve attitudes to rule breakingAddress the type of violation that has become routineApply clear consequences for individuals and their managersImprove intervention skills