Managing Rule Breaking Hearts & Mind Tools Managing Rule Breaking Understanding Your HSE Culture Managing Rule Breaking Improving Supervision Risk Assessment Matrix etc. This slide package is designed to introduce the topic of not following or breaking the rules. With “rules” we mean actually everything that defines how things should be done properly. It is recommended to use this presentation in combination with the brochure” Managing Rule-Breaking” (EP 2001-5278). It can be used as the introductory presentation mentioned at section 3.2 of this brochure. Human Error and breaking of rules is one of the most common causes of accidents.

Managing Rule Breaking Workshop Objectives: Awareness on why people break rules Identify areas of weakness in PDO Agree Action Items for improvement Review how to improve Compliance This slide package is designed to introduce the topic of not following or breaking the rules. With “rules” we mean actually everything that defines how things should be done properly. It is recommended to use this presentation in combination with the brochure” Managing Rule-Breaking” (EP 2001-5278). It can be used as the introductory presentation mentioned at section 3.2 of this brochure. Human Error and breaking of rules is one of the most common causes of accidents.

Human Error and Violations Tools Human Error and Violations This slide package is designed to introduce the topic of not following or breaking the rules. With “rules” we mean actually everything that defines how things should be done properly. It is recommended to use this presentation in combination with the brochure” Managing Rule-Breaking” (EP 2001-5278). It can be used as the introductory presentation mentioned at section 3.2 of this brochure. Human Error and breaking of rules is one of the most common causes of accidents.

PDO & Contractors HSE Performance 1986 - 2002

Historical Trend in Safety Injuries Engineering Systems: Hardware issues to engineer out hazards Management Systems: develop procedures, etc. to control hazards Focus on People: empowerment to Work Safely Time Early Stage Development Now People make the difference

HSE Management Hazard/ Risk WORK Undesirable outcome Barriers or Controls HSE Management is about Good understanding of the world in which you operate and the work Identifying what can go wrong and lead to undesirable outcomes with consequences to health, safety environment or reputation Putting barriers in place to prevent escalation from left to right; these barriers can be of a variety of natures: design procedures hardware: PRVs, gas detection, fire fighting capability seatbelts, PPE etc. etc as nothing in this world is perfect there are holes in the barriers indicating a possibility of failure (looks like Swiss Cheese) to keep holes as small as possible and make sure that they do not align: Assign tasks to people to create barriers and keep them in place Ensure people are competent for their tasks Provide people with instructions and standards Communication essential information to each other about malfunctioning barriers, so that others can make sure that their barrier remains effective A large percentage of the holes in the barriers/controls are due to Human Error. Estimates vary from 80 to 96% Therefore, understanding Human Error is important. The next slide explains the various types of human error

Why are Violations Dangerous ? + Error = DISASTER A maintenance supervisor decides to keep production going by not performing required electrical isolation (violation). An operator, knowing maintenance is taking place, decides to fix another problem, while assuming the process is isolated (error). He gets electocuted ! Initially a split is made in intended and unintended actions Unintended actions: Slips are usually benign, not so dangerous on their own. Usually you get an immediate reminder that you are doing the wrong thing. Example: if you drive a car in a country with traffic on the other side of the road, you will switch your windscreen wiper on when you want to turn right. Lapses are more dangerous, harder to contain. You forget to do something and are not immediately reminded. Example: You forgot to fill up your petrol tank. Mistakes are even more dangerous, you intend your action and ignore counter-evidence that says that what you are doing is wrong. Example: you are driving along a road which has a speed limit of 100 km/h. Your actual speed is 95 km/h which is within the speed limit. You turn off the road onto another road which looks no different and continue at 95 km/h. However, a police seed trap catches you speeding as the limit on the road you have turned onto has a speed limit of 80 km/h. Violations are deliberate and break a fundamental assumption of a Safety Management System: procedures will be followed. A violation removes a barrier/control and opens the path to disaster. One violation is not necessarily disastrous. However, in combination with another violation from somebody, who also assumes that other barriers will remain in tact, and slips or lapses (holes in barriers) is the recipe for disaster. Example: A pool car has a speed limiter on it set at 80 km/h. A driver gets in the car and finds this frustrating as he has to sit at 80 km/h for a long journey although the road he is driving on is designed for a maximum speed of 80 km/h. He then tampers with the speed limiter by cutting a wire to disengage the speed limiter. He then completes his journey and hands in the car to the car pool. Another driver gets in the following day and drives the car. He goes above 80 km/h and the speed limiter does not engage. While going round a tight bend above 80 km/h he rolls the car and injures himself. An alternative way to presenting this slide to avoid throwing up the definitions is to ask the participants what they would immediately say to a police officer after a police officer had stopped them for overtaking a police car where the police car was travelling at exactly the speed limit. Get each participant to write down very quickly what they would say to the police officer and then you as the facilitator write them up on a flipchart. Then go through each one and discuss if each is a intended action (violation or a mistake) or a unintended violation (lapse or slip) – then bring the definitions into the ensuing discussion. Passengers in a car are not wearing seat belts (violation) during a journey. Driver overtakes in a road section (error) and becomes involved in a roll-over whilst trying to avoid head-on collision. Passengers are thrown out of the vehicle and get killed ! Basic Error Types

Why do people not follow the rules ? Write down reasons for breaking the rules There is no right or wrong answer !! ? Use a flipchart to make an inventory of the various reasons as they are experience by the supervisors and workforce. Experience learns that in 5 minutes the vast majority of reasons come to the surface. The next slides summarizes the various reasons in six categories.

Types of violation Rules are incorrect, unclear, burdensome Rules are OK but communication of them and training is at fault It has become the normal way of doing things Cannot do the job without breaking the rules. More convenient/pleasing, satisfy the boss, fun, kick Novel situations for which there is no guidance Six types of violations can be distinguished. Unintentional (quality/clarity): Rules are incorrect, unclear, burdensome Unintentional (distribution/training):Rules are OK but distribution and training is at fault Routine: it has become the normal way of doing things, everybody is doing it and it is usually known by supervisors who condone it by not commenting Situational: discrepancy between what is required by the rules and the limited resources and suitability for the given situation. Situational factors include time pressure, high workload, unworkable rules, inadequate equipment, poor staffing, poor supervision, bad conditions Optimising: doing things more conveniently, more pleasing, trying to please the boss by finishing in time, showing off etc, or just for the fun of it. Taking pride in doing it faster than anybody else. Exceptional: novel, difficult or dangerous situations in which there may not be any procedural guidance. The questionnaire helps to identify which of the types of violations is most prevalent in your organisation and provides focus for an effort to eliminate violations

Do you really mean all of this, everywhere on this location? This slide can be used to explain routine violations resulting from to many rules which are not taken seriously e.g many signs at a drilling location with offices, storage areas etc. The rules on the board are not necessary everywhere on this location so it is more or less left to the people to decide when to apply the PPE

Questionnaire Read the questions and assess which response aligns best with your personal work environment. Scratch open only one cell per question Results are anonymous Read the questions and assess which response aligns best with your personal work environment. What we will do later is take the information from this questionnaire and see if the problems lie in the rules and procedures and/or in the compliance with the rules and procedures. We will then derive action plans from these problems to take back to our work places to either improve the rules and procedures and/or the compliance with the rules and procedures. Scratch open only one cell per question Results are anonymous

Findings from Questionnaire 1 Rules easy to understand 2 Procedures easy to understand 3 Some procedures are complicated 4 Procedures are without cross- reference 5 Procedures incorrect Total

Findings from Questionnaire 6 Unable to check whether people understand procedures 7 Easy to get printouts of the rules & procedures 8 Some times come across strange procedures 9 Aware of the applicable rules & procedures 10 Need to know procedures for personal tasks only Total

Findings from Questionnaire 11 Procedures not properly described 12 Procedures make job Safe & Efficient 13 Same rules broken regularly 14 Aware that the best way to do my work is in procedures 15 No shortcuts at all 16 Can do the job by ignoring some rules 17 Rules apply to all workers 18 Most rules not necessary for job safety 19 Supervisors ignore some violations 20 Some rules only to cover management Total

Findings from Questionnaire 21 Schedules give enough time to follow the rules 22 Right equipment as per the procedures always available 23 Sometimes work environment prevent following the rules 24 Rewards for breaking some rules 25 Managers sometimes support breaking rules 26 Staff shortage result in breaking rules 27 Most procedures are easy to apply 28 Supervisors know about rule breaking situations 29 Rule bending required to achieve target 30 Possible to do job without bending rules Total

Findings from Questionnaire 31 Rules sometimes too restrictive 32 Sometimes don’t know why follow specific procedures 33 Never want to do work outside my responsibility 34 No financial rewards gained from breaking rules 35 Regular breaks given for repetitive and boring jobs 36 Following the rules removes skill element 37 Deviate from rules to show special job knowledge 38 Personal benefits gained by following rules & procedures 39 Interesting to do the job in different ways 40 Can always work here and keep rules Total

Findings from Questionnaire 41 Never had unfamiliar situations 42 Know using procedures in unusual circumstances 43 Sometimes work in situations without any procedures 44 Some rules provoke breakage 45 Never have unfamiliar problems in job Total

Human errors and violations Intended action Unintended action COACHING Violation Mistake Lapse Slip Initially a split is made in intended and unintended actions Unintended actions: Slips are usually benign, not so dangerous on their own. Usually you get an immediate reminder that you are doing the wrong thing. Example: if you drive a car in a country with traffic on the other side of the road, you will switch your windscreen wiper on when you want to turn right. Lapses are more dangerous, harder to contain. You forget to do something and are not immediately reminded. Example: You forgot to fill up your petrol tank. Mistakes are even more dangerous, you intend your action and ignore counter-evidence that says that what you are doing is wrong. Example: you are driving along a road which has a speed limit of 100 km/h. Your actual speed is 95 km/h which is within the speed limit. You turn off the road onto another road which looks no different and continue at 95 km/h. However, a police seed trap catches you speeding as the limit on the road you have turned onto has a speed limit of 80 km/h. Violations are deliberate and break a fundamental assumption of a Safety Management System: procedures will be followed. A violation removes a barrier/control and opens the path to disaster. One violation is not necessarily disastrous. However, in combination with another violation from somebody, who also assumes that other barriers will remain in tact, and slips or lapses (holes in barriers) is the recipe for disaster. Example: A pool car has a speed limiter on it set at 80 km/h. A driver gets in the car and finds this frustrating as he has to sit at 80 km/h for a long journey although the road he is driving on is designed for a maximum speed of 80 km/h. He then tampers with the speed limiter by cutting a wire to disengage the speed limiter. He then completes his journey and hands in the car to the car pool. Another driver gets in the following day and drives the car. He goes above 80 km/h and the speed limiter does not engage. While going round a tight bend above 80 km/h he rolls the car and injures himself. An alternative way to presenting this slide to avoid throwing up the definitions is to ask the participants what they would immediately say to a police officer after a police officer had stopped them for overtaking a police car where the police car was travelling at exactly the speed limit. Get each participant to write down very quickly what they would say to the police officer and then you as the facilitator write them up on a flipchart. Then go through each one and discuss if each is a intended action (violation or a mistake) or a unintended violation (lapse or slip) – then bring the definitions into the ensuing discussion. Accountability for HSE Rule-based Knowledge-based Memory failures Attentional Failures Awareness of Procedures ? Basic Error Types

Creating Compliance Career Development Small rewards, souvenirs Financial rewards Personal Safety Dropping some other requirement Praise & Encouragement Group Processes Forcing Conditions (MoG Truck Drivers JM compliance) Accountability for HSE & Discipline How many people violate?. Studies on North Sea Offshore platforms have confirmed that some 70 % of the people violate. A study in the North Sea found 2 dimensions Sheep - Wolves Sheep don’t like to violate, wolves don’t mind Sheep are the Guardians of High Standards Wolves are go-getting opportunists Wolves are Natural Born Violators Sheep’s clothing - Wolves’ clothing Your ‘clothing’ shows if you have violated recently Ask audience: “Why do you violate?” (usually you will hear a number of reasons that can be linked to the categories on the next slide

Worksite Conditions Questionnaire: Wolf or Sheep? 1 Do I always follow rules ? 14 If I take shortcuts, it makes life easier 16 Mainly up to me, to take shortcut or not 17 It’s ok for someone of my experience to cut corners 18 You can bend rules, if.. 19 I wouldn’t run into problems, even if… 20 I know when there is a better way 21 If I bent the rules, I will feel bad afterwards Total

Results of questionnaires Do not accept violations 22 % Sheep 34 % Wolves in Sheep clothing 14 % Sheep in wolves clothing 30 % Wolves How many people violate?. Studies on North Sea Offshore platforms have confirmed that some 70 % of the people violate. A study in the North Sea found 2 dimensions Sheep - Wolves Sheep don’t like to violate, wolves don’t mind Sheep are the Guardians of High Standards Wolves are go-getting opportunists Wolves are Natural Born Violators Sheep’s clothing - Wolves’ clothing Your ‘clothing’ shows if you have violated recently Ask audience: “Why do you violate?” (usually you will hear a number of reasons that can be linked to the categories on the next slide Accept violations Never Violate Violate

First, Break all the rules Airport Bookshop First, Break all the rules What the Worlds Greatest Managers do differently by Marcus Buckingham & Curt Coffman The session can be closed of by explaining that some rule breaking has the potential for significant improvements. For example,. if somebody finds a way to do a job twice as fast by ignoring one rule, it may be worth considering whether that rule can indeed be (temporarily) relaxed by putting in some additional precautions to ensure that the other barriers remain in tact or installing an additional barrier. Managers do this all the time. They are born wolves. Violation is the exercise of initiative Violations are ways of finding improvements Definition of an Engineer- Someone who says: “There must be a better way of doing this” “If we do it this way we can save a fortune” “Tomorrow I’ll follow the book, but today I’ve got to get the job done” People are hired to exercise initiative So, we hire violators!

Action Plan: What shall we do differently ? Ensure relevant procedures are available and known Understand why your team is breaking Rules Do not hesitate to challenge Rule if INAPPROPRIATE Create atmosphere for COMPLIANCE Encourage and INSIST on COMPLIANCE Do NOT Compromise, and never walk away from non-compliance As a last resort, you may have to use PENALTY etc, etc The session can be closed of by explaining that some rule breaking has the potential for significant improvements. For example,. if somebody finds a way to do a job twice as fast by ignoring one rule, it may be worth considering whether that rule can indeed be (temporarily) relaxed by putting in some additional precautions to ensure that the other barriers remain in tact or installing an additional barrier. Managers do this all the time. They are born wolves. Violation is the exercise of initiative Violations are ways of finding improvements Definition of an Engineer- Someone who says: “There must be a better way of doing this” “If we do it this way we can save a fortune” “Tomorrow I’ll follow the book, but today I’ve got to get the job done” People are hired to exercise initiative So, we hire violators!