Why people don’t follow procedures

Shipping is a heavy-regulated business due to the nature of its operations that make it a risky sector to work in. Things that go wrong by not following standards can lead to loss of life. The rule-makers, e.g. a shipping company making an SMS, have to manage thousands of procedures and work instructions, but those will never be able to address all possible scenarios of what can go wrong in the dynamically changing reality of everyday operations. So how efficient can the investigations, that identify “lack of compliance with procedures” as the root cause of an incident, be?

Sometimes, non-conformance is not happening intentionally and with malicious aims, but rather in the context of many other people trying to achieve their different -and possibly contradictory- objectives. In many cases, circumstances change or are not as predicted by those who designed the procedures, says Professor Sidney Dekker from Griffith University in Australia. And this is exactly when safety is shifting, from a simple result of following procedures to the complex result of human insight into the circumstances.

The Safety I vs Safety II debate

The ‘Safety II’ concept argues that we should stop focusing only on how to stop things from going wrong but emphasize on why things go right instead. The ‘Safety-II’ perspective acts as an evolutionary complement of the conventional safety thinking, known as ‘Safety I’. The more recent approach to safety comes to dislodge the interest from ’what goes wrong’ to ‘what goes right’, reminding us that safety management should not only be reactive, but proactive as well.

In ‘Safety II’, humans are seen as a resource necessary for flexibility and resilience. But in an era where human error is attributed to the majority of maritime casualties, the view of humans as a safeguard and not a liability will be the foremost challenge.

Safety I

• Learn from our errors
• Reactive approach
• Understand what goes wrong

Safety II

• Learn from our successes
• Proactive approach
• Understand what goes right

Non-conformity in shipping

Non-conformance or nonconformity is the failure to meet specified requirements, thus, to follow procedures. A non-conformance can be minor, which means it would be unlikely to lead to major consequences. However, a major non-conformance means failure to meet critical safety requirements and standards, which could lead to human loss, injury, or severe damage.

According to IACS, a “major non-conformity” in shipping means an identifiable deviation that poses a serious threat to the safety of personnel or the ship or a serious risk to the environment that requires immediate corrective action or the lack of effective and systematic implementation of a requirement of the ISM Code.

What are the main reasons for non-conformity?

Research has generally identified at least the following factors as reasons why people may not comply with procedures at work:

• Practicality – There is a gap between theory and actual working routine.
• Overconfidence – People sometimes tend to rely on their own skills and experience.
• Lack of clarity – Life has imagination and sometimes it may be hard to find the information you need in a procedure.
•  Accessibility – Sometimes it is just not feasible to reach the procedures during the actual time of the task.
•  Lack of comprehension – There is no evidence from the employees’ perspective that procedures would help them do their job better or faster.

The way forward on safety compliance

Based on the above, it could be said that the way forward for organizations with an innovative approach to safety is to mind and comprehend the gap between procedures and practice. In the cases where the procedures were not followed, the company has the opportunity to unveil a potential mismatch between how the job was imagined and the everyday job reality.

And this is where the concept of Safety II comes to validate itself, rejecting the “punish” approach. While the blame culture of the “punish approach” -in line with the Safety I concept- is intended to address non-conformance, this has been proven to actually bring opposite results. Blame impedes trust and lack of trust impedes the psychological safety needed for employees to be able to speak up about anything that goes wrong. And when employees are not willing to share what goes wrong, leaders lose their chance to be informed about issues and address them before it is too late.

The way forward for a change of mentality seems long in an industry that has traditionally learned to shed focus on near-miss reporting, but not on positive reporting. And of course, a critical and always relevant consideration for effective management of procedures should begin with the integration of procedures into training.