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Journal ArticleDOI

Working to rule, or working safely? Part 1: A state of the art review

01 Jun 2013-Safety Science (Elsevier Publishing)-Vol. 55, pp 207-221
TL;DR: A review of the literature from 1986 on the management of those safety rules and procedures which relate to the workplace level in organisations can be found in this paper, where the authors compare two different paradigms of how rules and their development and use are perceived and managed.
About: This article is published in Safety Science.The article was published on 2013-06-01 and is currently open access. It has received 275 citations till now. The article focuses on the topics: Poison control.

Summary (4 min read)

1. Introduction

  • The focus of this paper is on safety rules and procedures used at the workplace level in organisations.
  • The guidance uses the word ‘procedures’ frequently, to talk both about directing and controlling the safety of the primary processes of the organisation and to specify the activities of the safety management system itself (hazard identification, risk assessment, communication, participation, monitoring/auditing, emergency response, etc.).
  • Rules and procedures are seen as largely desirable and certainly unavoidable to allocate responsibility (and later blame in many cultures and organisations) and to define and guide behaviour in complex and often conflicting environments and processes Behind this logical, rational obviousness, however, there lies another ‘truth’ about the reality of safety rules and their use.
  • One is a top-down, rational, optimistic view of rules reflecting the first paragraph above; the other is a constructivist view of how rules operate, which turns the dark side revealed in Elling’s study and its later counterparts on its head and proposes a bottom-up, participative approach to rule emergence to avoid such negative attitudes.

1.2. Safe envelope of operations: the objective of rules

  • Rasmussen (1997) introduced the valuable (if abstract) notion of a drift to danger, whereby an SMS establishes a safe zone of operation, guarded by risk controls.
  • These zones also define types and functions of rules; for defining the control measures to be taken to navigate within the boundaries, to avoid going over the boundary (itself defined by rules) and to recover under emergency conditions from a position outside the boundaries.
  • The “rule of three” (Hudson et al. undated) is one example from the offshore oil and gas industry where the boundary of safe operations becomes visible through enhancing decision makers’ situation awareness of a range of work environment and other factors that could push the system across the boundary and into disaster.
  • If only one critical dimension is red, then operations cease.
  • For cases judged to be in the amber zone, the decision to halt operations escalates as the number of critical dimensions judged as amber increases from one to three.

1.3. Categorisation of rules

  • Hale & Swuste (1998) introduced a useful distinction between different types of rules, which has been taken up by Blakstad (2006) (see also Blakstad et al 2010) and Grote et al (2009) in their analysis of rule management in railways (see also Energy Institute 2008 and Rasmussen 1997).
  • Hale & Swuste (op.cit.) point out that every time a person carries out a piece of behaviour the authors should realise that a translation process has gone on at some point from the appropriate performance goals, through the process rules to an action rule for that behaviour at that moment in time.
  • Decentralising rule making requires that translation to be done at lower levels in the hierarchy, a process which the authors can truly call self-regulation.

1.4. Structure of the paper

  • The authors will focus this paper on the use of rules and procedures for those working in the primary processes of hazardous technologies, the machine operators, fitters, pilots, surgeons, nurses, anaesthetists, etc.
  • The authors will only touch in passing on the value and management of rules and procedures at the level of the safety management system, or the rules of the regulator imposed on that level.
  • The authors believe that there may be interesting parallels to draw with these levels and refer the reader to a number of papers listed in a separate annex.
  • The question of writing rules for safety culture was discussed in detail at a workshop run by the New Technology and Work Network in December 2010 (e.g. Grote 2010, LeCoze & Wiig 2010, Kringen 2010).
  • The paper begins with a section (2) specifying what the two models introduced in section 1.1 are, followed by a section (3) over what the support for each model is and what the strengths and weaknesses of rules devised under each model can be.

2. Contrasting models of (safety) rules2

  • Dekker (2005) was the first to formulate the two models of safety rules in explicit terms, calling them ‘model 1’ and ‘model 2’.
  • There is a wide range of earlier literature, which the authors will analyse, that points to this dichotomy of thinking about rules, deriving from different theoretical traditions and evidence bases.
  • The authors draw, in the short sections below, a brief and somewhat stylised sketch of each model before going into the literature which they have used to derive that sketch.

2.1. Model 1

  • This model is rooted in Scientific Management (Taylor 1911, McCarthy et al 1998) and is rationalist and prescriptive in its approach, appealing to engineering concepts and truths.
  • It sees rules, particularly action rules, as the embodiment of the one best way to carry out activities, covering all known contingencies.
  • They should be derived and devised in advance, based on task and risk analysis.
  • Once devised, they are ‘carved in stone’, communicated to, and imposed on, the operators or workforce by management (their elders and betters), to be enforced by suitable means to overcome the fallible human tendency to make errors and deviate from the rules, either intentionally or unintentionally.
  • This is in some ways a caricature of the model, and there have been many attempts to file down its sharper edges, which the authors shall discuss below.

2.2. Model 2

  • This model, which has emerged from sociological and ethnographic studies particularly of high technology and complex industries, such as aviation and health care, sees rules (in the organisational literature often called ‘routines’) as patterns of behaviour, socially constructed, emerging from experience with actions and activities by those carrying them out.
  • Variability, driven by human adaptation to diversity is inevitable and valuable (Hollnagel 2004) and must be managed and not supressed.
  • Therefore effort needs to be focused on incorporating operators’ experience into rule design.
  • It is this gap between rules and reality which is seen as ‘causing’ or explaining the apparent deviations and violations.
  • The literature is more nuanced than that and the authors believe it supports a view that elements from both models have their place in rule management, a case they argue in the companion paper to this one (Hale & Borys 2012, this issue).

3.1. Model 1

  • Much of the research inspired by model 1 has been aimed at trying to understand, explain and counteract violations from imposed or agreed rules, which are themselves seen as the ‘gold standard’ of correct behaviour.
  • The results can be summarised under the headings used by Alper & Karsh (2009) for their review, see table 1, which also incorporates findings from the other papers in the list in the previous sentence which were not reviewed by Alper & Karsh.
  • The work of Drach-Zahavy & Somech (2010) revealed the qualitative trade-offs people were making in deciding whether to comply with safety procedures.

3.2. Contrasting model 1 with model 2

  • Marchand et al (1998), working from a social psychological paradigm of model building demonstrated in a study of 898 workers from manufacturing firms drawn from different technologies, hazard ratings and accident rates that it was not only the score on the scales measuring compliance with rules that was predictive of accident rate.
  • The inevitability of violations, indeed their positive necessity, in contrast with the negative image of them in model 1, is also emphasised by Besnard & Greathead (2003).
  • Amalberti (2001), in a paper discussing the improvement of technologies that are already ultra-safe, warns of the danger of increasing regulations and procedures beyond a certain point; more rules then simply mean more violations and a stultification and suppression of creativity to be able to operate outside the boundary of the envelope defined by safety procedures (see section 1.2 above).

3.3. Underpinning model 2

  • The expert has goals and process rules to cope with diversity and complex and fine-grained sets of personal and tacit action rules derived from long application of those process rules.
  • In the health-care sphere (McDonald et al 2005, 2006, Parker & Lawton 2000, Høyland et al 2010) it is the doctors, and particularly the surgeons, who are most negative about rules/protocols and most positive about the need for violations.
  • Conchie & Donald (2008) and Schöbel (2009) point to the need to balance trust in rules with mistrust, leading to a critical view of rules and their applicability and a culture that will support checking and monitoring of the behaviour of others (institutionalised mistrust), manifest in turn as the challenging of violations.

4. Summary & Conclusions for the management of rules

  • The review of the two models of rules and their development and use has resulted in the definition of a broad set of concerns and dilemmas.
  • The picture that emerges is of a gap between the reality of work and its routines and the abstraction of the (often written) rules that are supposed to govern it and guide behaviour to carry out that work safely (see also Borys 2007).
  • Central also is the need to see rule sets as dynamic and to place the focus of their management on the processes around monitoring and change , rather than purely on development and communication.
  • The authors also believe that much of what they have said in this paper is not limited to the use and management of safety rules.

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Citations
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Journal ArticleDOI
TL;DR: In this paper, an extensive literature review on the field of Resilience Engineering (RE), encompassing 472 contributions, including journal articles, conference proceedings and book chapters, is presented.

212 citations

Journal ArticleDOI
TL;DR: In this paper, the authors present a framework of rule management which attempts to draw the lessons from the literature from 1986 on the management of those safety rules and procedures which relate to the workplace level in organisations.

170 citations

Journal ArticleDOI
TL;DR: In this paper, the author examines the bureaucratization of safety, and the increase in safety as measurable bureaucratic accountability, and concludes with possible ideas for addressing such problems, including a reduced marginal yield of safety initiatives, bureaucratic entrepreneurism and pettiness, an inability to predict unexpected events, structural secrecy, "numbers games," the creation of new safety problems, and constraints on organization members' personal freedom, diversity and creativity, as well as a hampering of innovation.

148 citations


Cites background from "Working to rule, or working safely?..."

  • ...…procedures and bureaucratic protocol can actually harm safety in certain circumstances (Dekker, 2001): ‘‘major accidents such as Mann Gulch and Piper Alpha have shown that it can be those who violate rules who survive such emergencies, whilst those who obey die’’ (Hale and Borys, 2013b, p. 214)....

    [...]

  • ...E-mail address: s.dekker@griffith.edu.au Contents lists available at ScienceDirect Safety Science journal homepage: www.elsevier .com/locate /ssc i sees ‘violations’ as negative behavior to be suppressed (Hale and Borys, 2013a, 2013b)....

    [...]

  • ...…expansion of safety are common across nations and activities—e.g. increases in rules, paperwork, costs, time drain, safety people involved, and compliance expectations that are insensitive to the demands of front-line activities (GAO, 2012; Hale, 1990; Hale and Borys, 2013b; Hale and Swuste, 1998)....

    [...]

Journal ArticleDOI
TL;DR: In this paper, the authors investigate and describe safety culture and risk-taking at a large steel-manufacturing company in Sweden by exploring workers' experiences and perceptions of safety and risks.

120 citations

Journal ArticleDOI
TL;DR: A just culture is defined as "the conditions that legitimize managerial intervention in the sanction or restoration of individuals in the organization" as discussed by the authors, which aims to respond to anxiety about blame-free approaches on the one hand and a concern about people's willingness to keep reporting safety-related issues on the other.

113 citations


Cites background from "Working to rule, or working safely?..."

  • ...And realistically, some may not even have the space to fully familiarize themselves with every regulation that pertains to their work (Hale and Borys, 2013a,b)....

    [...]

  • ...It is to allow workers themselves play a genuine role in the development of safety standards (Bergström et al., 2009; Dahl and Olsen, 2013; Hale and Borys, 2013a,b; Hale et al., 2013)....

    [...]

References
More filters
Book
01 Jun 1975

36,032 citations


"Working to rule, or working safely?..." refers background in this paper

  • ...the theory of planned behaviour (Fishbein and Ajzen, 1975)....

    [...]

  • ...Such studies link to the extensive literature exploring the theory of planned behaviour (Fishbein and Ajzen, 1975)....

    [...]

Book
01 Jun 1978
TL;DR: Aguilar et al. as discussed by the authors define intervencion as "entrar en un conjunto de relaciones en desarrollo con el proposito de ser util".
Abstract: «... Intervenir es entrar en un conjunto de relaciones en desarrollo con el proposito de ser util. El tipo de ayuda en el que nos vamos a centrar consiste en aumentar la capacidad para una buena dialectica organizativa —es decir, la capacidad de indagacion organizativa para encajar errores, incongruencias e incompatibilidades en una teoria organizativa de la accion la cual necesariamente emerge a medida que el sistema organizativo/ambiental cambia» (p. 158). «... Nuestra actividad en la intervencion debe por tanto ocuparse de tres propositos. Estos son: 1) ayudar al cliente a ser consciente y a descongelar sus teorias al uso del Modelo I y sistemas de aprendizaje O-I, y 2) educar al cliente a usar el Modelo II y a crear sistemas de aprendizaje O-II, para 3) usar este nuevo conocimiento con el fin de lograr una buena dialectica organizativa. Llamamos a la actividad de intervencion que incluye las tres intenciones una intervencion extensa» (p. 166).

10,772 citations


"Working to rule, or working safely?..." refers result in this paper

  • ...Again this is somewhat of a caricature of the model, but it is clear that its main thrust is to differentiate the written from the acted rules in much the same way that Argyris and Schön (1978) distinguish ‘espoused theory’ from ‘theory-inuse’....

    [...]

Book
01 Jan 1911
TL;DR: The Taylor System as discussed by the authors was developed as a system for increasing productivity in industry, and its principles have been applied to all kinds of large-scale enterprises, including operations with departments and agencies of the federal government.
Abstract: This brief essay by the founder of scientific management has served for nearly a century as a primer for administrators and for students of managerial techniques. Although scientific management was developed primarily as a system for increasing productivity in industry, its principles have been applied to all kinds of large-scale enterprises, including operations with departments and agencies of the federal government. It is in this volume that Frederick Winslow Taylor gave the theory of scientific management its clearest airing. Born in 1856, Taylor began work at age eighteen as an apprentice to a pattern-maker and as a machinist. A few years later he joined the Midvale Steel Company as a laborer, and in eight years rose to chief engineer. During this time he developed and tested what he called the "task system," which became known as the Taylor System and eventually as scientific management. He made careful experiments to determine the best way of performing each operation and the amount of time it required, analyzing the materials, tools, and work sequence, and establishing a clear division of labor between management and workers. His experiments laid the groundwork for the principles that are expounded in this essay, which was first published in 1911.

5,361 citations

Journal ArticleDOI
TL;DR: The KatzNewcomb lecture as mentioned in this paper celebrated the life of Rensis Likert, the founding director of the Institute for Social Relations, who was born in 1903, which meant this lecture also celebrated their 90th birthdays.
Abstract: This is a revised version of the KatzNewcomb lecture presented at the University of Michigan, April 23-24, 1993. The 1993 lecture celebrated the life of Rensis Likert, the founding director of the Institute for Social Relations. All three people honored at the lecture-Dan Katz, Ted Newcomb, and Ren Likert-were born in 1903, which meant this lecture also celebrated their 90th birthdays. I am grateful to Lance Sandelands, Debra Meyerson, Robert Sutton, Doug Cowherd, and Karen Weick for their help in revising early drafts of this material. I also want to thank John Van Maanen, J. Richard Hackman, Linda Pike, and the anonymous ASQ reviewers for their he lp with later drafts.

3,856 citations

Frequently Asked Questions (13)
Q1. What are the contributions in this paper?

The paper reviews the literature from 1986 on the management of those safety rules and procedures which relate to the workplace level in organisations. The paper explores the research underlying and illustrating these two paradigms, drawn from psychology, sociology and ethnography, organisational studies and behavioural economics. In a separate paper following on from this review ( Hale & Borys 2012, this issue ) the authors propose a framework of rule management which attempts to draw the lessons from both paradigms. 

He does recognise that rules can never be complete and compliance should never be blind, but sees the solution in a modification to model 1, not its scrapping. 

March & Simon (1958) saw them as essential building blocks for control, to be adapted to diverse situations by judging their appropriateness. 

These zones also define types and functions of rules; for defining the control measures to be taken to navigate within the boundaries, to avoid going over the boundary (itself defined by rules) and to recover under emergency conditions from a position outside the boundaries. 

The four topics found to be relevant can be summarised as follows:1. Individual characteristics suggest a relatively stable personality trait linked to over-confidence, an effect of risk perception, one of poor planning, and the effect of a risk-taking culture. 

It is also a dominant view of rules, at least in high risk organisations, as shown in a study by Bax et al (1998) who found that 72% of a representative sample of Dutch workers in such organisations worked in organisations with (many) formal rules, half of the organisations having regular or frequent formal controls of those rules. 

For a second offence in a short time 83% of supervisors said they would report the offender to higher management for sanctions; 70% of miners agreed, but only 53% of miners believed the supervisor would actually do so. 

This is the model which is triggered by the media response to major accidents, in which violations of rules are identified which contributed to the accident and more stringent or more extensive rules are called for to prevent recurrence. 

It is also the model which powers much of behavioural based safety (e.g. Krause et al 1999, Keil Centre 2002) as a set of tools to achieve workforce compliance. 

These included their need to demonstrate their care and concern for their patients, causing them not to want to wear PPE against infections for fear of the patients sensing revulsion, and a neglect of their own safety when it clashed with that of their patients or the speed they needed to show in responding to patient emergencies. 

An often used classification system for violations is that based on Reason’s (1990) work, further developed by the work of Free (1994) – see also HFRG (1995). 

Rules under this heading include requirements of a process to prepare a risk assessment, either generically or at the last minute before starting work, requirements to set up a safety management system, and requirements to consult with defined people when an emergency situation arises in order to decide how to handle it. 

Dekker (2005) points out that the negative image linking violations and major accidents is based on fallacious reasoning, which takes no account of the thousands of occasions when violations led to positive outcomes (and were relabelled innovations or expertise) rather than to accidents.