8/20/2021

Why people don’t “follow” procedures…

S. Camille Peres, PhD

Motivation Issue with procedures

Attributed to majority of
incidents in high risk
industries
Individual or Group Decision-Making

Quality of Hazard Mitigation

Quality of Task Execution

Communication

Personnel Skills or Knowledge

Quality of Task Planning and Preparation

Emergency Response

Management of Change

Work Direction or Management

Risk Assessment and Management

Operating Procedures or Safe Work Practices

Instrument, Analyzer and Controls Reliability

Process or Equipment Reliability

Process or Equip Mat Spec, Fab and Const

Process or Equipment Design or Layout

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0%

https://www.chron.com/local/bayou-city-history/article/30-years-ago-The-Phillips-Petroleum-explosion-in-14563155.php#photo-18500733 2013 2014 2015 2016 2017

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Objectives:

• Groundbreaking research into

human factors & technology

• Define best practices &

establish new Human-Factors
standards

• Provide framework to increase

ADVANCED NEXT GENERATION PROCEDURE RESEARCH
productivity, human reliability,
and safety

• Apply findings to new

technologies and interfaces

Research Methods Low-fidelity virtual

simulation

High-fidelity simulation

Interviews &
Observations

Eye tracking

Summary—
Regulations & “Best Practices” Surveys

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Some of Our Major Findings

1. Much of current guidance not based on empirical research

2. Units within a single facility differed remarkably regarding health of procedural system

3. Concerning reports regarding procedure deviation and use

4. Procedure cannot be one size fits all

5. Written procedures likely never completely perfect

6. Current guidance regarding hazard statement designs is likely wrong

7. Procedure use based on quality, usefulness, and worker experience

Finding 1: Guidance often not based on empirical

findings

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Summary of Current Guidance

▪ Identified current regulations, standards, & guidelines.
o ISO, EPA, OSHA, SEMS, NRC, INPO, & UK

▪ Found elements and ideas common to each.

▪ Identified empirical research

to provides guidelines to writers.

Findings
Element Type # of Common # of Considerations # of Guidelines
Elements from Needed for Human identified from the
Regulations & Performance literature
Standards
General procedure
3 None 11
requirements
Types of procedures 7 40 4
Normal Operating Limits
3 12 2
and Ranges
Hazard Exposures 6 24 6
Management of
2 8 1
Procedures

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I’d see it within a week or two,

you know? Now if it’s some kind
of big emergency. . . I’m sure
they could get on the phones and
talk to each other and get that
done fast.”

Finding 2: Units within facilities differed remarkably

on the health of their procedural systems

“I wrote four of them, and it
took almost a year before
they got processed.”
“…we have procedures out there right
now that we know are wrong. . . we try to
get them changed and redline them, but
until that gets changed, we know…(it) isn’t
feasible to do.”

Finding 3: Concerning reports regarding procedure

deviation and use

- Supervisors requiring deviation from procedures due to time & production

pressures
- Workers wanted supervisors to be held accountable
- Workers followed procedures to protect from liability—ignoring quality
- More focus on “watching their back”

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Finding 4: Procedure cannot be “one size fits all”

Deviation, use, incidents reliably varies by:
- Task frequency
- Worker experience
- Step word length

Finding 5: Written procedures likely never

completely perfect

Revision process likely related to :

- Safety climate
- Procedure Use

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Worker Engagement
▪ Head of HSE for BP Wells
o “When we started tracking the turnaround time for redlined procedures, procedure
adherence improved remarkably. We tell them that we measure what’s important, so
we showed them that their feedback was important.”

▪ VP Plains All American

o “If an area had a high level of [procedure] modifications (all mods were tracked) we
believed that it indicated the operators were sincerely using their procedures. The
hydrocracker often had the highest procedure modifications per month within the
refinery.”

Finding 6: Communicating safety information

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Hazard Statements

▪ Safety critical information

▪ For consumer products,
design matters

▪ VERY little investigation

when embedded in
procedures

Previous Results
1
Laboratory Environment Naturalistic Simulation
0.9 87.0%
1
0.9 0.8
81.1%
77.5%
0.8 0.7
Compliance Rate

0.7 0.6 55.6%

0.6
0.5
0.5
0.4
0.4
0.3
0.3
0.2 0.2

0.1 0.1

0 0
Icon Absent Icon Present No Icon (n = 54) Icon (n = 27)

p = 0.006 p = .017

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Why do we see this?

Is it an attentional issue?

Good Design

Bad Design

Why do we see this?

Is it an attentional issue?
Illustration of Mediation Effect
Good Design
1
0.89
0.9
0.79 Good
0.78
0.8 Bad
0.7 Bad Design
Proportion Compliance

0.58
0.6
0.5
0.4
0.3
0.2
0.1
0
Without Fixation With Fixation

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Why do we see this?

Is it an attentional issue?
Mediation Effect
Good Design
1
0.89
0.9
0.79 Good
0.78
0.8 Bad
0.7 Bad Design
Proportion Compliance

0.58
0.6
0.5
0.4
0.3
0.2
Good (+) Time (+)
0.1
0
Hazard St.
Without Fixation With Fixation Fixation Compliance
Design

Finding 7: Predictors of Procedure USE

Stepwise multiple regression for Procedure Use

Beta t p
Procedure quality 0.218 -2.792 0.006
Attitude toward procedure utility 0.186 -2.425 0.016
Years experience in industry -0.145 -1.997 0.047

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Summary

What is a
“good procedure”?

▪ Ensures effective performance

▪ Facilitates safety
▪ Communicates risks
▪ Documents compliance

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Is this realistic?

▪ Can a document be reliable & effective hazard barrier?

o Evidence says “no”
https://documentaryheaven.com/crash-of-flight-111/

▪ Example:
o Passenger aircraft crash in 1998
o Pilot focused on checklists
• Ignored co-pilot’s suggestion to descend
and dump fuel

Halifax, Nova Scotia

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Workers’ double bind

Dekker, S. (2003). Failure to adapt or adaptations
that fail: contrasting models on procedures and
safety. Applied ergonomics

▪ Worker rigidly follows rules when conditions indicate procedure is wrong

—leads to unsafe outcome
oWorker blamed for inflexibility and application of rules without sensitivity to context

▪ Worker deviates to unanticipated condition without certainty of outcome

—leads to unsafe outcomes
oWorker gets blamed for deviation or non-adherence
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“Safety results from organizations

Procedures & Safety monitoring and understanding
Model 1 & 2 the reasons behind the gap
between procedures and practice.
▪ Safety Model 1 Additionally, organizations must
o Control of worker paramount develop ways that support
o Procedures should be followed rigidly
people’s skill at judging when and
o Safety comes from this control
how to adapt.”
Dekker, S. (2003).
▪ Safety Model 2
o Procedures are resources for action
o Applying procedures successfully a substantive & skillful cognitive activity
o Safety results from skill at judging when & how to adapt procedures to local
circumstances
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What is an effective Procedural System?

▪ Procedures tool for safe and effective performance

o Not accountability method for management

▪ Procedures are physically validated

▪ Continuous quality checks of procedures which insures:

o Procedures easy to use
o Tasks easy as possible to perform
o Workers take ownership of procedures
o Short turnaround for redlined
procedures

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Back to the Double Bind

▪ Digital Procedures with automation can facilitate

o Workers’ communication about gaps between procedures and practice
o Organizations’ monitoring the reasons behind these gaps

▪ With this information, organizations can

o Develop ways to support people’s skill at judging when and how to adapt

Review of Findings
1. Much of current guidance not based on empirical research

2. Units within a single facility differed remarkably regarding health of procedural system

3. Concerning reports regarding procedure deviation and use

4. Procedure cannot be one size fits all

5. Written procedures likely never completely perfect

6. Current guidance regarding hazard statement designs is likely wrong

7. Procedure use based on quality, usefulness, and worker experience

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Investigators
 Camille Peres
Students  Joe Hendricks Contact Info
 Atif Ashraf  Mark Mackey  Farzan Sasangohar peres@tamu.edu
 Stefan Dumlao  Dieu Wu  Ranjana Mehta advancedprocedures.tamu.edu
 Trent Parker  Walid Zaar
 Tony McDonald
 Alec Smith  Hayder Alhilo
 Elliott Lander
 Changwon Son  Morgan Kaplan
 Kianna Arthur  Hannah Payne Follow us
 Addi Arbia  Erin Maddix Next Generation
Advanced Procedures
 Conrad Forkheim  Yasmin Safian
@NxGnProcedures

Overview of
Human Factors & Ergonomics Society (HFES)
• Christopher R. Reid, PhD, ATF – HFES President-Elect (The Boeing Company)
• S. Camille Peres, PhD – HFES Code of Ethics Revision Task Force Chair (Texas A&M University)
• Keith Jones, PhD – HFES Program Accreditation Committee Chair (Texas Tech University)
• Carolyn Sommerich, PhD – HFES Diversity & Inclusion Committee Chair (Ohio State University)

Society of Petroleum Engineers-Human Factors Technical Session

August 20, 2021

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Alphonse Chapanis
Father of Human Factors
WWII B17s
• Landing after combat mission
• Pilots and copilots
• Retracting landing gear instead
of landing flaps

Human Factors & Ergonomics Society (HFES)

• Mission:
• Advance the science and practice of
designing for people in systems
through knowledge exchange,
collaboration, and advocacy.

• HFES envisions a future

of systems that work
for humans by design, Photo by Chevanon Photography
from Pexels

grounded in science.

Photo by JC Gellidon on
Unsplash
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Exploring the Possibilities…

• Knowledge sharing and creating equal opportunities for

students and faculty to explore the field of Human Factors &
Ergonomics (HF/E)
• Introduce engineering students to the field
• Form partnerships for engagement with experts
• Enrich dialogs with diverse people and perspectives

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Connecting to HFESConnecting to HFES

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HFES Technical Groups (TGs)

26 TGs focus on HF/E application areas & methods.
TGs oversee technical content of conferences & provide opportunities for engagement and
leadership roles for HFES members, including students.

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Synergies & Collaboration Opportunities

Information and Education • Opportunities to share information about HF/E at
Exchanges conferences, symposiums, webinars, etc.

Cooperative Education
• HF/E Co-Op and Internship opportunities
(Co-Ops) and Internships

Career Fairs • Learn about careers in HF/E and future work opportunities

• Connect with and learn from mentors and senior leaders in

Leadership Development HF/E & HFES

Research/Project • Share across university borders in cross-disciplinary, cross-

Opportunities geographical, and multi-institutional work

• HF/E student exchange programs, satellite programs, and

University Alliances institutional partnerships

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HFES Contacts for Next Steps

HFES Leadership:
• Peter Hancock, President
• Susan Kotowski, Secretary-Treasurer
• Steve Kemp, Executive Director
Further Questions:
• S. Camille Peres, PhD – HFES Code of Ethics Revision Task Force Chair
• peres@tamu.edu
• Christopher Reid, HFES President-Elect
• christopher.r.reid@boeing.com
• Steve Kemp, Executive Director
• skemp@hfes.org

We need you and we think you need us…

QUESTIONS, SUGGESTIONS, IDEAS?!

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