Dear User, This presentation has been designed for you by the Hearts and Minds Support Team

1. Dear User, • This presentation has been designed for you by the Hearts and Minds Support Team • It provides a guideline for conducting a Managing Rule Breaking workshop • The presentation has been supplied with speaker notes and has been checked for correctness and relevance • Please note that all the examples have been chosen to support people from all industries • Please, feel free to replace them with your own examples and/or add any slides and exercises you find useful • We hope you will find it useful • Best regards, • The Hearts and Minds Support Team

3. Managing Rule Breaking

5. Managing Rule Breaking • WHAT • A simple tool that explains why people break rules • WHY • To help establish a culture of compliance and working safely that will assist in achieving Goal Zero • HOW • By helping to understand why people break rules and how to manage and change this behaviour

6. The Swiss Cheese Model

7. Why break the rules?

8. Do not accept violations 22% Sheep 34% Wolves in Sheep Clothing 14% Sheep in Wolves’ Clothing 30% Wolves Accept Violations Never Violate Violate Wolves and Sheep OPTIONAL SLIDE

9. Types of Rule Breaking: Errors • Slips • Doing something one did not mean to • “You decide to stop adding sugar to your coffee and then find yourself doing it anyway ” • Lapses • Forget to carry out an action • “You are on your way to work when the thought strikes you: Did I lock the door?” • Mistakes • The chosen plan was wrong • “The doctor makes a wrong diagnosis and as a result prescribes the wrong medicine”

10. Types of Rule Breaking: Violations • UnintentionalIncorrect/unclear rules or faulty communication and training • “Because they did not know the procedures operators were not using correct PPE” • SituationalImpossible to do the job without breaking the rules due to lack of resources • “A technician discovered that the tool they were supposed to use does not fit in the space available. They used a different tool instead” • Optimising • More convenient, profitable, pleasing the boss, fun • Organisational: For the benefit of the organisation/boss“Not to cause any production losses a maintenance worker decides to fix a broken relay without turning off the electricity supply” • Personal: For the benefit of the individual “In order to get home in time a person is driving 70 km/h where the speed limit is 50 km/h”

11. Types of Rule Breaking: Special Violations • Reckless Optimising ViolationA rule was violated without thinking or caring about the consequences • “Drunk Driving” • RoutineAny violation that has become the normal way of doing things • “Crossing the street on the red light whenever there are no cars” • Exceptional • Novel, extreme situations for which there is no guidance • “A man dies while trying to save a child”

12. When a hazard is present Violation + Error = DISASTER

13. Examples • Violation: Someone walks behind a truck without informing the driver • Mistake: Believing it is safe, the driver selects reverse gear • Result: The driver runs the person over • Violation: A driver is not wearing their seatbelt • Error: A driver takes a bend too quickly on a slippery road • Result: The vehicle rolls over • Violation: A driver on the outside lane is speeding • Error: A driver on the inside lane forgets to look in the mirror when switching lanes • Result: Collision

14. “In order to avoid production losses and start work on time, it has become common practice to skip an important but lengthy check” How Do You Know

15. Procedures and Practices Questionnaire • Individually: • Complete the Procedures and Practices Questionnaire • In Groups: • Compute the group average for each violation types • If the average is less than a ‘critical score’ discuss that type of rule breaking • If several areas are identified, focus on Exceptional Violations last • If routine violations are identified • What was the original violation type?

16. Discussion • Discuss your scores with the group: • Is there a certain type of rule breaking that might be an issue? • Which category is it? • What type of problem does it cause? • Why? • Is there specific rule or procedure causing it? • Do you have any own examples? • What were the specific problems there?

17. Reasons for No Procedures • Procedures may cause problems as they: • Become more complex over time • Are written with unrealistic assumptions • Often are an overly simplistic solution to a hard problem • Their level does not match the user OPTIONAL SLIDE

18. Reasons for Procedures • Complicated jobs • Long instructions • Non-obvious safety checks and standards • Information for safe and effective operation • Define the steps order when alternative sequences are possible • Define common work practices • Ensure everyone “plays the same game” • Information transfer as new people arrive OPTIONAL SLIDE

19. Writing a Good Procedure • Involve your team in a process • Review what happens in practice • Remember: people make mistakes • Define the end-user • Check HSE requirements • Identify critical sequence activities • Place memory aids • Try it out • Define review criteria • Update on regular bases OPTIONAL SLIDE

20. Writing Good Procedures • Use short sentences • Use active voice • Be direct Tell the reader what to do • Use short words (“Raise” instead of “elevate”) • Do not use abbreviations or acronyms • Be consistent with terminology • Do not assume the reader knows something • Put steps in the right sequence OPTIONAL SLIDE

21. Improving Safety By Improving Procedures • Are the existing procedures • Correct? • Available? • Understandable? • Actually understood? • Are there any unnecessary ones you could get rid of? • Do resources and circumstances allow rule-following? • Is rule following rewarding? • Do people feel comfortable to use their initiative without risks? • Is the improvement progress reviewed regularly? OPTIONAL SLIDE

22. Group Debate • EXAMPLE: SPECIFIC PROCEDURE • What is its purpose and which hazards does it control? • Do we need it? • What are the consequences of removal? • Are all the hazards still under control? • What if the removal is not possible?

23. Creating Compliance Creating ComplianceDiscussion • How can we be more compliant? • Compliance through consequences Reward or Punishment • Group Pressure What hazards are being managed? What type of accidents could take place? What are the advantages of non-compliance? Is it worth the risk? Will individuals comply if enforced by the group? Are there alternatives to compliance? How will the group ensure compliance? How does a group create compliance? • Forcing Functions Is there a way of ensuring compliance by creating a situation in which there is no opportunity to violate? OPTIONAL SLIDE

24. Creating Compliance Rewards and Punishment • Rewards and recognition • Takes time to work • Rewards need to be given close in time to the behaviour being rewarded • Often small non-material rewards work best • Personal praise and recognition is particularly effective • Punishment • Effective in the short term • Problem: people are likely to change their behaviour to avoid punishment rather than to act safely • Must be seen as just and fair OPTIONAL SLIDE

25. Creating Compliance Group Pressure and Forcing Functions • Group pressure • Through competition between groups or using group rewards • Only works if people want to be part of the group • To be effective, group needs to last at least six months • To be effective, group should contain some people already doing the right thing • Forcing functions • Ways to force behaviour • A vehicle will not start unless the seat belt is used • The mobile phone on/off switch is connected to the handbrake circuit (brake off, phone off) • You can only start shift during the tool-box talk OPTIONAL SLIDE

26. Action Plan • How can we be more compliant? What are you going to do? Who will do it? When will it be done? Who and when will review it? Is your Action Plan SMART: Specific? Measurable? Achievable? Realistic? Time based?

27. Questions

28. Backup Slides

29. Examples of violations

30. An Unintentional Violation • Example of poor procedure/instruction: • PR 1508 LIFTING TUBULARS • The slings should be doubled wrapped with a choke hitch taking care not to cross over the sling on the underside of the pipe or pipe bundle. The choke hitch should be pulled tight to secure the bundle and a bulldog grip fitted. A tie wrap should then be fitted to prevent the reeving eye slipping over the bulldog. The included angle between the choke hitches shall not exceed 120 degrees

31. Another Unintentional (Routine) Violation It is OK here… or not? Clearly on obstruction here and no parking Vehicle wheel clamped for violation

32. Types of Rule-Breaking: A Situational Violation • It is sometimes impossible to get the job done while following the rules • A steel worker was killed when they fell 20 m from a structure under construction. After investigation it occurred that even though harnesses were provided there was no provision for fixing the broken ones and there were no other safeguards available. As the workers were afraid of losing their jobs if they refused to work, they kept on using the broken harnesses while fulfilling their tasks.

33. A Personal Routine Violation • Rules are broken in order to reach a personal goal. Additionally, everyone involved feels the rules are irrelevant and they no longer appreciate the dangers of the situation Everyone does it like that!

34. Personal Optimising Violation • Rules are broken in order to reach a personal goal • Because they were in a hurry to get home early, instead of asking for a scaffold, a construction worker used their own ladder to tighten a screw at 5 m height.

35. Organisational Optimising Violation Done with the intention of achieving organisational goals. Getting the job done faster, cheaper etc During the conceptual design of a project, a number of environmental considerations are dropped in order to reduce costs and speed up the work

36. Reckless Violation • A rule was violated without thinking or caring about the consequences • A fuel tanker driver knows that lack of attention can cause an accident, possibly resulting in an explosion, but still uses a mobile phone while driving at high speed on a busy highway.

37. Exceptional Violation • When your friend is overcome by H2S the human reaction is to want to help them, whereas the rule (correctly) says leave them and get help. Often the first person survives but those who try and help without BA usually die • When attacked by a bear lie down in front of it and keep very still and quiet (unless it is a black bear, in which case screaming seems to work best) • During the Piper Alpha incident, a couple of the crew decided to leave the mustering area whereas most of the crew stayed-put (the rule said so). Those who made the former choice, survived

38. Low Cost Motivators • Write a letter of commendation • Ask employees for advice/opinions • Give verbal praise • Pass along compliments you received from others • Write an e-mail/memo to a superior and cc the employee • Put positive information in the employee’s productivity file • Provide quick follow up on problems/hazards when recognised • Post positive achievements on the safety bulletin board • Say “Thank You” and mean it • Allow flextime • Designate special parking places • Give out award plaques, trophies or diplomas • Feature an employee of the month • Recognise peers that have helped you • Have a coffee/juice morning to acknowledge accomplishments • Thank somebody that contributes ideas, regardless on whether you use it • Always give others credit when due • Create group awards to recognise teamwork • Ask the employees how they want to be recognised • Ask a superior to write a memo acknowledging an accomplishment for your employee • Post complimentary letters on the safety bulletin board • Send employees to special seminars and workshops that may interest them • Safety Day • Safety Olympics • Safety T-Shirts • Dinner for two gift • Certificates • Weekend stay at bed & breakfast

39. Three Levels of Procedures • Rules and Guidelines • Define acceptable operating standards • Define Good Practice • Assume a level of operator competence • Work Descriptions • Operate within Guidelines • Describe advisory steps, actions and sequences • Require co-ordination with more people • Work Instructions • Step by step requirements • For use in critical or complex situations • Defined for operators with lower basic competencies • Often required legally

40. Safety Improvement • Remove Procedures • Rewrite Procedures • Job Redesign • Job enlargement • Job enrichment • Flexible working groups, including job rotation • Workforce Involvement • Variance Permits • Enforcement

41. Managing Violations

42. Managing Violations

43. Managing Violations

44. Managing Violations