Aftermarket: Part II Why Good Employees Violate Procedures — What We Can Do About It?

Part I of the article outlined the staggering costs of Procedural (Intentional) Non-Compliance (PiNC), how PiNC facilitates losses, and how people are hard-wired to a degree of PiNC behaviour (see AM, February 2007, page 20). Part II will briefly outline the situationally dependent nature of PiNC, how work-adaptive behavior can be harnessed to create operating efficiencies, and offer some recommendations that create more beneficial conditions for compliance as well as more effective procedures.

The Situational Nature of PiNC

Even though system designers and organization managers attempt to provide adequate procedures with satisfactory safety margins, procedures may not be able to accommodate all of the situational conditions that people encounter. We could neither afford nor imagine procedures for every possible condition. The best we can do is to effectively proceduralize routine operations and expect employees to use their best professional judgements to reconcile non-standard situations using higher-level organizational goals and policies.

For the purpose of this discussion, we are not considering abnormal situations in which employees intentionally disregard published procedures; we are discussing procedural non-compliance during routine operations in light of existing procedures, whatever their quality.

Sometimes an employee disregards a good (valid) procedure — which would be a bad decision — yet the situation produces a good outcome. For example, Scottish scientist Alexander Fleming was researching the influenza virus in 1928 when he noticed that a blue-green mold had infected one of his petri dishes that he failed to handle according to standard laboratory procedures. The mold killed the staphylococci bacteria growing in it. We know that mold as penicillin. He was situationally lucky. However, society demands greater assurances from high-risk enterprises than luck; adhering to valid procedures increases the likelihood of predictable outcomes.

Sometimes employees disregard a bad (invalid) procedure — which may be good. The situation is such that by happenstance PiNC produces a good outcome, which may be both good and bad. Good that no loss eventuated. Bad in that the flawed procedure may remain in the operating system and since there was no loss in that instance, there may be little awareness or motivation to correct the procedure; it remains an organizational latent failure. (See Figure 1)

We must also consider that the concept of "situation" is significantly more complex than a simple catalogue of the operating conditions. Other factors also impact upon employees’ assessments of a situation: peoples’ relationships with the organization, with peers, with what is happening in their personal lives, with customers and others. Given identical circumstances, different employees may evaluate the situation quite differently.

Do you know of procedures in your organization that are less than adequate to some degree: inappropriate, poorly written, or just ignored by employees because the procedures are not relevant to the current conditions?

A Rational Explanation

A sub-category of PiNC may be termed Logical (Intentional) Non-Compliance (LiNC) with procedures. This situation eventuates when it is obvious to employees that the original conditions for the procedure no longer exist. Employees "logically" reconcile the current conditions and available resources to satisfy production expectations and in so doing, they are procedurally non-compliant.

We know that one of the most prevalent conditions for LiNC is a failure to effectively manage procedures¹, which are frequently implemented and little, if any, validation of their continued appropriateness occurs — until there is a loss.

Another factor increasing the likelihood of LiNC is the inevitable production creep organizations experience when attempting to maximize profits from existing resources. It is understandable that "good" employees would use their ingenuity and determination to develop efficient work-arounds to meet production targets in light of the organizational, environmental, and situational conditions — often at the expense of the published procedures and safety margins.

The organization may be dimly aware of employee work-arounds and may even unwittingly encourage LiNC and PiNC activity by rewarding top performers, which acts as encouragement for other employees to also adopt LiNC and PiNC behaviors. The drift to degrading levels of safety and losses is incremental; therefore, there may be few obvious signals for managers to observe, especially since in many organizations production expectations tend to creep incrementally upward at a pace faster than supporting resources.

Additionally, few organizations reward employees for complying with procedures — it is considered expected behavior — and few organizations actually discipline non-injury, non-damage PiNC occurrences 1. Therefore, there is little motivation for employees to adhere to procedures and there may seem to be a number of apparent benefits to PiNC activity.

Generally, people do not intentionally set out to violate procedures; they set out to do a good job. Production imperatives, operational conditions, and situational factors can combine to create situations conducive to LiNC and PiNC behavior.

Work-Adaptive Behavior and Efficiencies

Let us consider that operational employees are hands-on system experts and that as resource maximizing agents, they naturally seek ways to complete tasks using the minimum expenditure of effort. Effective organizations create environments that recognize the abilities of line operators to improvise efficient ways to operate. They institutionalize the processes of feedback, evaluation, and implementation of improved work adaptations.

Managers that formalize a procedure management process¹ and proactively encourage feedback from employee specialist experts can discover operational efficiencies, develop an appreciation for the current production processes, and create a more effective flow of communication. They may also discover degrading margins of safety that might be unacceptable to organizational expectations.

Joint Responsibility

Managers can unwittingly create the conditions for PiNC, yet professional line operators also share a significant responsibility in the violation equation. Managers can make mistakes in developing procedures and allocating resources; however, employees have a duty of care to provide timely feedback regarding specific details of how procedures are not producing the intended results or are contributing to potential losses. Line operators, especially those licensed by the authorities, have a responsibility as the last line of safety defences to discontinue hazardous operations.

However, the degree of responsibility for PiNC behavior shifts more toward the organization when: organizations demonstrate a "shoot the messenger" attitude to employees; organizations make explicit or implicit demands for employees to meet increasing production targets; or when organizations do not provide adequate resources for employees to operate according to the procedures.

How effectively organizations manage this joint responsibility plays a significant part in the overall loss management equation.

Managerial Flawed Assumptions

There are several assumptions that managers can make that lead to the existence of PiNC conditions:

• An organizational expectation that good managers create good procedures. The results of the Internet Survey 1 discussed in Part 1 indicate this may not be the reality.

• The existing procedures are adequate for the current situation. Managers should assume all procedures are inadequate to varying degrees until validated by key employees actually using the procedures.

• Most people adhere or will adhere to procedures. As discussed in Part 1, humans are hard-wired to a degree of PiNC.

Unless and until managers understand and take measures to address these basic flawed assumptions, there is every logical reason to expect organizations would have procedures that were less than adequate, which gives the opportunity for employees’ PiNC and possibly LiNC decisions.

Employee Flawed Assumptions

Research in 1996 validating the Behavioral Cause Model determined that managers could predict employee violating behavior by understanding four primary conditions, which the scientists termed, "The Lethal Cocktail" 2:

When the organizational and situational conditions are such that employees estimate that they are justified to adapt to these conditions, we could expect LiNC and PiNC to flourish — along with the predictable losses. It could prove to be a revealing exercise for managers to survey key employees to determine the extent of these conditions within an organization. Ask employees what they expect they will have to do to complete a task, not what they intend to do. The answers could reveal areas for management interventions.

Intolerance for PiNC

Clearly an organization’s viability depends upon its predictable delivery of products or services, the well being of its customers and employees, and obtaining maximum service life from equipment. When employees adhere to valid procedures appropriate to routine operations, margins to accommodate the unexpected may be maintained and profitability may be possible

For managers having any reservations about taking a strong stance regarding undeniably PiNC events, empirical evidence has indicated that violations are a statistically significant, positive predictor of accident involvement, even after the effects of exposure, age, and gender had been partialled out 2.

Organizations cannot tolerate the effects of PiNC and managers need to use appropriate administrative sanctions to make it an unattractive option. However, there are essential caveats for managers to satisfy before undertaking disciplinary measures:

1. a. The procedure was valid

2. b. The employee undertook training and understood the procedure and its rationale

3. c. Required resources to perform the procedure were present

4. d. There was no logical reason why the employee should not have followed the procedure

With these caveats satisfied, for managers to hesitate taking appropriate disciplinary action may be more detrimental to the organization than an employee’s PiNC behavior.

Reducing PiNC / LiNC 1

The following suggestions are not to be taken as the definitive guide to reduce PiNC; they are intended as a starting point for managers to evaluate in light of their organizations’ conditions and requirements. The degree to which an organization is able to concurrently integrate this suite of recommendations would determine the degree of effectiveness managing PiNC. There is abundant science regarding the development of procedures available to anyone with an interest via the Internet. The following actions are possible strategies for managers:

1. 1. Educate senior management that organizations are asking employees to control their basic natures regarding risk in favor of conduct to deliver assured production safely and profitably, which appears to be more difficult for people than imagined.

2. 2. Assume that all procedures are flawed to some degree until those doing the actual tasks have validated the procedures.

3. 3. Accept that most people are good employees trying to do a good job. If they are intentionally non-compliant, then there may be an organizational component to the equation that requires rectification. Before blaming, ensure the procedure is relevant and ensure that others would not have done the same in similar circumstances.

4. 4. Nominate a procedure management champion and authorize that person to take whatever measures may be required to ensure the delivery of effective and valid procedures to the operating system.

5. 5. Develop an organizational procedure management program.

6. 6. Develop a clear methodology to investigate PiNC events:

   1. a. Why did the employee intentionally violate the procedure:

      1. i. As a result of an emergency?

      2. ii. As imposed by the situation?

      3. iii. As desired by the employee?

      4. iv. As a routine course of events within the system, do most employees do it that way?

   2. b. Evaluate the procedure:

      1. i. Is it appropriate?

      2. ii. Are there sufficient resources to perform the procedure as published?

      3. iii. Is it right?

      4. iv. Was the employee trained in the procedure? Did they understand the procedure?

   3. c. If the procedure is valid, the employee was trained and understood the procedure, and the situation did not present any compelling reason for the employee not to adhere to the procedure, if warranted, terminate the employee’s services.

7. 7. Train a group of line operators to help with investigations of PiNC and near miss events; it makes them part of the improvement and communication processes.

8. 8. Eliminate economic motivators and other employee dilemmas conducive to PiNC.

9. 9. Educate employees and managers that people characteristically underestimate the level of risk and overestimate their abilities to handle increased risk.

10. 10. Convince people that procedures are defensive barriers to risks; they are designed to protect employees and society. Make everyone aware that people who violate are disposed to accidents and that data indicates that they make 25 percent more errors of other types.

11. 11. Warn people to be aware that they may not be the only ones violating procedures in a system — if their intentional non-compliance meets someone else’s error, the result could be catastrophic.

12. 12. Develop and publish a clear policy that the organization will not tolerate intentional non-compliances and those responsible for such actions shall be accountable.

13. 13. Reward and recognize adherence to procedures.

14. 14. Feed back the effects of PiNC events throughout the organization. Provide short examples of adherence to procedures as well as PiNC events on a frequent basis.

These interventions do not rely on technology, additional staff resources, or other resources beyond those already required to accomplish tasks safely. For the most part, they require the political will to take an unambiguous position against intentional non-compliance of appropriate procedures, a focus of attention to control conditions that are conducive to violating, provision of effective procedures, and adequate resources.

Conclusion

As we have seen, employee intentional non-compliance is a complex issue and using a simplistic "blame and train" solution to PiNC is likely to do more harm than good. This type of approach is possibly fixing the wrong factor. We might ask if we have accurately assessed whether it is the employee that requires fixing or the conditions, resources, or procedures that require fixing? What do we gain through retraining the employee in the correct procedure only to return them to the same operational conditions in which they continue to operate LiNC or PiNC to meet organizational objectives?

If the situation is LiNC, the origin of the problem is likely organizational and requires managerial corrective action. If the situation is undeniably PiNC, the accountability resides with the employee.

The potential for losses to the air transportation industry are staggering and to manage those losses, we need to understand the dynamics of intentional non-compliance. Armed with an appreciation of human regard for risk and adaptation, managers should be better equipped to control the conditions that are conducive to PiNC. This is just a glimpse into the individual and organizational psychology of PiNC behavior as well as specific actions managers may begin to implement without delay.

References

1. 1. Mitchell, E. (2005). Strategies to Reduce Aviation Employees’ Procedural Non-Compliance. MSc Thesis, City University London. http://aviationsafetyadvisors.com/edthesis.pdf

2. 2. Hudson, P., Verschuur, W., Parker, D., Lawton, R. & Van der Graaf, G. (2004). Retrieved 2005, Bending the Rules: Managing Violations in the Workplace http://www.energyinst.org.uk/heartsandminds/docs/bending.pdf

Ed Mitchell, MSc., MRAeS, is a practicing aviation safety manager and is pursuing a PhD in air transport engineering with City University London. He is researching ways to reduce the number and complexity of published procedures while maintaining equivalent or higher levels of safety. Mr. Mitchell’s MSc thesis, which studied procedural non-compliance among air transportation employees, collected data regarding intentional non-compliance and presented strategies to reduce violation events, forms the basis of this two-part article.