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Procedures - Improving compliance
A Procedure Assessment Tool (PAT) for identifying problems of non-compliance
Introduction
This assessment tool has been designed to aid management
in understanding rule breaking or procedure non-
compliance. For simplicity this document assumes that the
generic term ‘procedure’ covers both rules (the control) and
procedure (the method). The Procedure Assessment Tool
(PAT) consists of a question sheet and an explanation of
how to analyse the answers given.
Before auditing procedure compliance it is necessary for
managers to ask themselves a number of questions.
• Do employees know and understand the procedures?
• Do we need all of these procedures?
• Are there situations when it is impossible to apply
procedures?
• Does the task itself encourage non-compliance?
• Is it possible to have a procedure for every situation?
• Are there alternatives to procedures?
Procedure non- compliance
Unintentional violations arise from procedures
which are impossible for people to follow or that
they do not know of or understand.
Routine violations result from automatic and
unconscious behaviour. An employee may
consider violation as an apparent low risk to
himself or the task. Violations are accepted by the
particular work group as the normal way of doing
things.
Situational violations result from the immediate
work space or environment, which make it difficult
for the employee not to commit a violation.
Factors such as time pressure, lack of
supervision, unavailability of equipment and
insufficient staff.
Optimizing violations occur when people try to
make a task more exciting or interesting, or wish
to impress or to relieve boredom. These are
common when people are involved in long periods
of monotonous work, (monitoring work) or tasks
where the rules are restrictive or seen as out of
date.
Exceptional violations are rare occurring in very
unusual circumstances e.g. an emergency, or
equipment failure. They can be the result of a
conscious decision or instinctive reaction.
Identifying problems
The potential risks from five types of non-compliance can be
identified by asking employees to indicate their level of
agreement with a number of questions. The answers will
allow the organisation to assess the extent of the problem at
a particular work site or location.
A question sheet is provided in the Appendix. Where more
than one set of procedures apply to a department or task then
separate sheets should be used for each.
The questions are scored on a five-point agreement scale
ranging from 1, strongly disagree; to 5, strongly agree.
Analysis
A comparative index of the risks due to non-compliance for
each violation type can be obtained as follows:
1. For the question sheets that relate to a single set of
procedures or task, add the ratings for each question and
then divide this total by the number of sheets to obtain a
mean rating for each question.
2. Add the mean question ratings within groups of ten
questions. This applies to the first four groups (questions 1-
10, 11-20, 21-30, and 31-4. For the fifth group add the five
mean question ratings (41-45) and double that value to
enable a comparison with the other groups.
The final totals are out of a maximum of 50; high scores
indicate problems with procedures. A score greater than 30
indicates that action is necessary to improve procedures or
the processes governing them. Checking individual question
scores or employee comments may clarify the nature or
location of the problem.
Possible solutions to some of the problems associated with
procedure non-compliance are given below
Unintentional violations (Questions 1-10)
• Check that existing procedures are correct, clear, and
not lengthy or complicated.
• Check that employees are aware of the procedures and
have been trained in their use.
High scores on questions 1 - 5 rather than 6 - 10 suggest that
the problem is with the procedures themselves. It is
important that procedures are written from the employee’s
viewpoint and are also in a format suitable for the task.
Where a series of actions are required, checklists are the best
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means for ensuring the task is carried out correctly. For other
situations a diagram may better represent the information.
High scores on questions 6 to 10, but not 1 to 5 suggests
problems with the distribution or knowledge of procedures
and the training associated with them.
Routine violations (Questions 11-20)
High scores are an indicator that employees believe of
procedures to be unnecessary or overly restrictive. If these
beliefs are incorrect, then hazard awareness training may be
necessary.
• Check that existing procedures are not unnecessary or
overly restrictive.
• Check with employees’ if alternative procedures or
more efficient methods for completing a task should be
used.
• Are there too many procedures? Reduce the number of
procedures, which by default reduces the number of
non-compliances.
• Ensure that employees are aware and understand
existing procedures.
If there is better or more efficient way of doing the job
employees may feel they are justified in adopting the new
way and not follow existing procedures. Routine non-
compliances allow the job or task to be performed in away
that is easier for the individual and therefore gets the job
done more quickly. Often groups of employees develop
alternative and sometimes more efficient practices that
management may wish to recognise as correct practice.
Rewriting procedures giving the employees ‘ownership’ of
the procedures will have a positive effect on compliance..
Ensure that people who use procedures know why they are
written:
• For the safety of the workforce,
• To improve the company’s profitability (and peoples
wages),
• To comply with national regulations.
• Procedures are not to protect managements back
Provide an explanation for the need of a procedure; identify
the risks to personal safety. Avoid safety rules which
represent do's and don’ts, contravention of which is
punishable.
Preventing routine non-compliance involves considering the
need for each new procedure before it is introduced.
Procedures are continually being updated to cover changed
working conditions and new equipment. They should also be
revised to prohibit actions implicated in some past accident
or incident.
Situational Violations (Questions 21-30)
High scores provide evidence of differences between what is
required by the procedures and what is possible to achieve
with limited resources. Alternative or improved working
methods should be considered if procedures specify the use
of certain equipment or number of people required for the
task but are unavailable.
Local solutions are necessary because the factors promoting
non-compliance are determined locally i.e. operating one
man short or a piece of important equipment has not been
repaired or replaced.
Much non-compliance arises because the situations in which
people are asked to work are far from ideal. Non-compliance
occurs in an attempt to complete the job under these
constraints. Procedure enforcement may fail under these
conditions if the supervisor feels that achieving targets or
completing the job conflicts with safety considerations.
Factors that promote non-compliances include time pressure,
high workload, unworkable procedures, inadequate
equipment, bad conditions, short staffing, and poor
supervision.
In addition to providing support for procedure compliance,
managers need to be aware of the effect of working
conditions on individuals attempting to do their job
according to the procedures
Optimising violations (Questions 31-40)
High scores could reflect people’s desire to complete the
task in a professional manner, but could also indicate human
weakness of 'getting a buzz', 'having a laugh', avoiding
boredom, or demonstrating skills to fellow workers.
Avoid giving ‘incentives’ for procedure non-compliances
i.e .bonus for achieving targets.
Simplify procedures to decrease the risk of boredom
associated with the job; make employees feel that they are
valued.
Relying on procedures to control the behaviour of highly
skilled employees may only serve to reduce the efficiency
gains made by employing and training such staff.
• Make the job more interesting. Redesign the task
through job enrichment and flexible working groups
• Redesign the procedure; involve the staff in writing and
evaluating procedures.
• Use incentives for procedure compliance and safety,
avoid punishing non-compliances
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Exceptional violations (Questions 41-45)
Training, rather than procedures will help to reduce the
occurrence of these rare, yet dangerous non-compliances.
People need to know how close they are to the limits of
safety.
Teach - 'think before you act'. Employees require the skills
necessary to deal with rare problems while at the same time
need to foresee the possible dangers associated with their
actions.
Exceptional non-compliances very often occur when an
employee is attempting to solve a difficult and unusual
problem for which there is no procedure and in the course of
solving the problem violates a safety procedure. This kind of
non-compliance is more frequent in jobs that require a great
deal of novel problem solving (e.g. maintenance activities).
An unnecessary reaction is to attempt to write procedures to
cover each novel situation as it arises; this is unlikely to
succeed as it only serves to make the employee less able to
solve problems and deal with novel situations. Furthermore,
it is virtually impossible to envisage a procedures manual
that contains sufficient procedures to cover all possible
hazards or hazardous situations.
Summary
Procedures are written to increase the predictability of
employees' behaviour. They are a means by which
organisations can attempt to control behaviour.
Auditing checks and actions:
• Ensure that existing procedures are correct, available
and understood.
• Check the training methods for procedure awareness
and use.
• Get rid of unnecessary procedures.
• Review the procedures for applicability.
• Make procedure following rewarding.
• Encourage employees to use their initiative without
taking risks.
• Check the way in which procedures are published and
distributed.
• Check that procedures are not kept on the shelf and
referred to only when a problem arises?
• If the employee need to know all the procedures in
detail, then personal copies are essential.
• Encourage compliance with the procedures; report non-
compliance
• Have a consistent and fair enforcement policy by local
supervisors.
• Management must continually monitor the ability of
employees to follow procedures.
• Consider alternatives to procedures, use automation,
error checking (duplicate processes or inspections).
+ + || + +
Source
This document is based on:-
‘BENDING THE RULES II’
‘Why do people break rules or fail to follow procedures?
and
What can you do about it?’
‘The Violation Manual’,
P T W Hudson, W L G Verschuur, Leaden University; R
Lawton, D Parker, J T Reason, Manchester University
A good procedure;
• has a clear and acceptable aim,
• has a scope which matches its
purpose,
• is precise, leaving no room for
doubt about its application in any
possible case (no loopholes),
• is certain to achieve the purpose,
without undesirable side effects.
All procedures must be SMART:
Specific,
Measurable,
Achievable,
Relevant, and
References
Non- Adherence to Procedures - Why Does it Happen? Arun
K. Karwal, Renate Verkaik 1 & Claartje Jansen
Non-Adherence to Procedures: Distinguishing Errors and
Violations by Patrick Hudson. Airbus 11th Human Factors
Symposium - Melbourne , July 2000
NZ CAA Airmanship & Maintenance rule breaking.
Vector 01-1
Preventing Human Error: Developing a Consensus Led
Safety Culture based on Best Practice
David Embrey PhD, Human Reliability Associates Ltd
On the Design of Flight-Deck Procedures
Asaf Degani, Earl L. Wiener
‘Developing Operating Documents, A Manual of
Guidelines’
NASA/FAA Operating Documents Project
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ADHERENCE TO STANDARD OPERATING

PROCEDURES: AN EFFECTIVE STRATEGY IN
ACCIDENT PREVENTION,
IATA Human Factors Working Group
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1 The procedures are not written in simple language 1 2 3 4 5

2 Some procedures are very difficult to understand 1 2 3 4 5
3 Some procedures are so complex that I lose track 1 2 3 4 5
4 Procedures commonly refer to other procedures 1 2 3 4 5
5 Some procedures are factually incorrect 1 2 3 4 5
6 No system exists to check people understand procedures before they are used 1 2 3 4 5
7 I sometimes have difficulty getting hold of written procedures and procedures 1 2 3 4 5
8 I sometimes come across a procedure I did not know about 1 2 3 4 5
9 I sometimes fail to fully understand which procedures to apply 1 2 3 4 5
10 I have procedures for tasks I will never have to do 1 2 3 4 5

11 The procedures do not always describe the best way of working 1 2 3 4 5

12 There are some procedures that make the job less safe/efficient 1 2 3 4 5
13 Infringements of some procedures occur all the time 1 2 3 4 5
14 I have found better ways of doing my job than those given in the procedures 1 2 3 4 5
15 Short cuts are acceptable when they involve little or no risk 1 2 3 4 5
16 I can get the job done quicker by ignoring some procedures 1 2 3 4 5
17 Some procedures are only for inexperienced workers 1 2 3 4 5
18 Some procedures do not need to be followed to get the job done safely 1 2 3 4 5
19 Supervisors turn a blind eye to some procedure non-compliances 1 2 3 4 5
20 Some procedures are only of value to protect management's back 1 2 3 4 5

What do you think about the company procedures?

This survey seeks your views on the availability, practicality, relevance, or need for company procedures. Please
complete separate forms if you are required to follow more than one set of departmental procedures; check the box
below indicating your department or for additional forms the departmental procedures that this form relates to.

Department:
Flight Crew
Cabin Crew
Ground Services
Ramp
Complete the table below by circling the number on the scale that best reflects
Maintenance
Otherlevel of agreement with each statement.
your

Statement Key
1= strongly disagree
2 = disagree
3 = neither agree nor disagree
4 = agree
5 = strongly agree
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21 Schedules seldom allow enough time to do the job according to the procedures 1 2 3 4 5
22 I sometimes can't get the equipment necessary to work to the procedures 1 2 3 4 5
23 Sometimes conditions at the workplace stop me working to the procedures 1 2 3 4 5
24 There are incentives to ignore some procedures 1 2 3 4 5
25 There are circumstances where managers will support procedures being broken 1 2 3 4 5
26 Staff shortages sometimes result in procedures being broken to get the job done 1 2 3 4 5
27 Some procedures are impossible or extremely difficult to apply 1 2 3 4 5
28 Supervisors recognise that in some situations deviations from procedures are unavoidable 1 2 3 4 5
29 It is necessary to bend some procedures to achieve a target 1 2 3 4 5
30 At certain times procedures have to be bent to keep the job going 1 2 3 4 5

31 Sometimes the operating limits prescribed in procedures are too restrictive 1 2 3 4 5

32 I sometimes don't know why I have to follow procedures 1 2 3 4 5
33 I am sometimes tempted to do work that is not my responsibility 1 2 3 4 5
34 There are financial rewards to be gained from breaking the procedures 1 2 3 4 5
35 I am not given regular break periods when I do repetitive and boring jobs 1 2 3 4 5
36 Working to the procedures removes skills 1 2 3 4 5
37 Deviating from some procedures demonstrates knowledge of the job 1 2 3 4 5
38 There are no personal benefits from strictly following procedures and procedures 1 2 3 4 5
39 Finding alternative ways of doing the job makes it more interesting 1 2 3 4 5
40 You can't move round here unless you do it by the book 1 2 3 4 5

41 I often come across situations with which I am unfamiliar 1 2 3 4 5

42 I have not been trained in the procedures to be used in unusual circumstances 1 2 3 4 5
43 I often encounter situations where no prescribed procedures are available 1 2 3 4 5
44 There are some procedures where your natural reaction would be to break them 1 2 3 4 5
45 I confront many novel problems in my job 1 2 3 4 5

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