Re-thinking 'Procedure not followed'

Mark Galley
Not the End of an Investigation

Organizations regularly use the term procedure not followed when conducting a root cause analysis.  If the documented way to perform the task wasn’t followed, then that label seems to fit.  But there’s much more to it.  Too many investigations stop at procedure not followed.  People see it as the smoking gun –  if the person would have just followed the procedure, the problem never would have happened.  The statement may be true, but it’s not complete.  Procedure not followed typically focuses on fixing the individual.  Corrective actions are directed at the person - review procedure with employee, brief employee, or maybe it’s disciplinary action like time off or termination.

Understand Work Process

Most of the opportunity to address procedure not followed is within the organization’s work processes.  Yes, the individual made an error, but it’s too narrow to focus on one person.  Someone else may have made the same mistake under similar conditions.  Specifics within the issue must be identified.  There are valuable solutions within procedure not followed, but it takes some digging.  Going forward, an organization doesn’t want anyone to make that same error.  Do you want to fix the person so he or she doesn’t do it again, or do you want to fix the work process, so no one does it again?  The investigation of one major aviation accident (by the National Transportation Safety Board) may result in recommendations that affect the operation of every aircraft.  Highly reliable organizations develop highly reliable work processes that evolve from lessons learned.

Procedure Clarity Spectrum

The term procedure not followed implies that the procedure is fine, the person just didn’t follow it.  But that assumption misses an important factor.  Not all procedures are good.  Some are terribly confusing and incomplete.  There is a spectrum for procedure clarity.  In motor vehicle accidents, it’s important to know if the driver was impaired or distracted.  Blood tests, cell records, driver statements, eyewitnesses and specifics about the scene provide detail about what happened.  That same diligence applies to your procedures.  Are any of your procedures impaired?  What test do you give the procedure to check clarity?  Should a knowledgeable person make that assessment, or should it be someone unfamiliar with the task?  Clarity to one person is confusion to another.  Does your process for developing procedures acknowledge that some people in your organization have 20-years of experience, but others have only 6-months?

How Much Detail

Managers, technical leads and the frontline have different opinions about how much detail is appropriate.  Most people want less detail to keep it simple.  If you’re going to the grocery store to get 20 items, do you only write down 12 of them?  Or do you write down all 20?  What approach does your organization take with procedures?  Do you write down every step?  Is each step only one action or do some steps contain multiple sub-steps?  Do people initial or check off each step?  Tasks can be explained at basic, mid and detailed levels.  Your procedure may need to zoom-in to more detail in some areas but zoom-out to less detail in others.  There’s always concern about adding too much detail to procedures.  People think adding detail, is overkill or dumbs down the task.  Don’t confuse dumbing it down with improving clarity.  Procedures can be confusing, but there are no procedures that are “too clear.”  Any critical details about a task should be kept in the procedure.  The clarity within a procedure reflects an organization’s tolerance of risk.  The more confusing or unclear the higher the risk.  There are over 14 work related fatalities each day in the United States.  What was about to happen just before each of those tragedies was not clear enough.  Don’t be concerned about too much detail. 

Comprehensive Record

Ideally, a company’s procedures reflect the sum of what the organization knows about its operations.  If your organization has been operating the same equipment or performing the same task for 25-years, then all the lessons about those systems from the past 25 years should be contained in the appropriate steps within the procedure.  A procedure is a storage device for organizational know-how.  Tribal knowledge shouldn’t reside only in people’s heads.  It should be captured within the company’s work processes.  This requires procedures to be updated as needed.  Within the process industry, just as piping and instrument diagrams (P&IDs) need to be red-lined and updated, so do your procedures.  Within many organizations, the process of updating a procedure is a mystery.  Frontline people have told us it’s just easier to leave the procedure the way it is – inaccurate – because “everyone knows what to do.”  That’s how operating outside of defined limits becomes normal. 

Involve the Users

What a person uses in the field as a checklist or work instructions may not be the comprehensive procedure.  Different job aids are acceptable to use if they’re part of the normal procedural review.  Organizations can be creative here.  What works best for the people in the field to perform a specific task should be determined by the people doing the work.  The front-line people are a resource.  What we typically find is they’re not being asked.  Front-line people are given procedures and checklists to follow.  Their insight and ideas are essential and need to be included.  The front-line knows what’s confusing and unclear.  In the book Managing the Unexpected, Karl Weick and Kathleen Sutcliffe called this ‘deference to expertise.’  People engage when their ideas are valued.  The front-line must be included in the development and evaluation of procedures.  For them to be responsible for results the front-line must have ownership in the work processes.  There’s a difference between taking orders and being an owner. 

Getting Started

There’s insight within every procedure not followed issue if you choose to access it.  So, experiment with this approach.  There’s always room to improve a work process.  It doesn’t have to be a wholesale change of how your company uses procedures.  Start small.  Pick one work process that’s a problem.  Dissect the steps and involve the frontline.  Ask what’s going well, what’s going poorly, what changes would they make, and where the task can be improved.  Can time be reduced, yet make risk even lower?  Any change to a work process, of course, needs a complete review to ensure it doesn’t create new problems.

We’re interested in hearing what you learn, so send us an email.  This is a skill you can develop that applies in all areas of a company.  If you’d like some help you can contact our office.  We can lead a pilot project with your group or you can attend one of our workshops.

Additional resources:

Review some of the root cause analysis examples on our website and let us know how we can help you with one of your safety incidents.  We can review one of your issues for you to compare what you’re doing now with what a complete cause-and-effect analysis looks like.  Contact our office for assistance.

DOWNLOAD: Cause Mapping Root Cause Analysis Template in Excel

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