Bending The Rules

BENDING THE RULES
THE VARIETIES, ORIGINS AND

MANAGEMENT OF SAFETY VIOLATIONS
Patrick Hudson
Bending the Rules: The Varieties, Origins and Management of Safety Violations.
CONTENTS
1. Scope..................................................................................................3
2. Introducing violations and procedures...............................................4
2.1. Errors and violations....................................................................4
2.2. Safe operating procedures..........................................................5
3. Performance levels.............................................................................6
4. Classifying violations..........................................................................8
4.1. Skill-based violations...................................................................8
4.2. Rule-based violations...................................................................8
4.3. Knowledge-based violations........................................................9
4.4. Transitions from KB to RB to SB................................................10
5. The behavioural economics of violating...........................................11
6. Personal factors influencing the perception of costs and benefits. .14
6.1. Common traffic violations...........................................................14
6.2. Age and gender.........................................................................14
6.3. Violations and road accidents....................................................14
6.4. Why do people violate on the roads?........................................15
6.5. Personality factors.....................................................................17
6.5.1. Accident proneness.........................................................................................17
6.5.2. Unstable extraverts..........................................................................................18
6.5.3. Compliance...................................................................................................... 19
6.5.4. Locus of control...............................................................................................20
7. Situational factors influencing violations..........................................21
7.1. Violation frequency and perceived risk......................................21
7.2. Why shunters violate..................................................................21
7.3. Predictors of shunting violations................................................22
7.4. Comparing the compliance of staff and management...............23
8. Organisational factors influencing violations....................................25
8.1. Procedural failures.....................................................................25
8.1.1. Skill-based or routine violations.......................................................................25
8.1.2. Ruled-based situational violations....................................................................26
8.2. Organisational failures...............................................................27
9. Counter-measures............................................................................29
9.1. Theory of Planned Behaviour....................................................29
9.2. Attempts to change individual attitudes to behaviour................29
9.3. The use of social controls..........................................................30
9.3.1. Pioneering the group decision technique.........................................................30
9.3.2. The Misumi studies..........................................................................................30
9.3.3. The Swedish Telecom studies.........................................................................31
9.3.4. The Manchester video study............................................................................32
9.3.5. Achieving changes in attitudes and beliefs......................................................32
9.4. Developing intrinsic motivation..................................................33
9.4.1. Competence and autonomy.............................................................................33
9.4.2. How events are perceived...............................................................................33
9.4.3. The effect of extrinsic rewards on intrinsic motivation.....................................34
9.4.4. The effect of external controls on intrinsic motivation......................................34
9.4.5. Promoting intrinsic motivation..........................................................................34
9.4.6. Group discussion leading to intrinsic motivation..............................................35
10. Summary and conclusions.............................................................36
2
1. Scope
Whereas errors have received close attention from human factors specialists for well over a
century, the study of violations is still very much in its infancy. Yet deviations from safe
operating procedures play a major role in accident causation, as was clearly shown by the
Chernobyl reactor disaster. Although this accident was initially said to have been due entirely
to human error, closer analysis showed that only two of the seven implicated unsafe acts
were errors, the remaining five were deliberate violations of safe operating procedures
(Reason, 1987).
Over the past decade there has been a growing appreciation of the many and varied ways
that people contribute to accidents in hazardous technologies. Not long ago, most of these
contributions would have been lumped together under the catch-all label of "human error".
Now it is apparent that the term "human error" covers a wide variety of unsafe behaviours.
One of the most important distinctions to be made is that between errors and violations. It is
clear that errors and violations have different mental origins, occur at different levels of the
organisation, require different counter-measures and have different consequences.
Assuming that a safe operating procedure is well-founded, any deviation from it will bring the
violator into an area of increased risk. The violation, of itself, may not have damaging
consequences; but the act of violating takes the violator into regions in which subsequent
errors are much more likely to have bad outcomes. Thus, violating increases the likelihood
that errors will lead to injury, damage or death.
The aim of this paper is to present a state-of-the-art report on violations.

Much of it is a digest of the research on violations carried out at the University of Manchester
and elsewhere over the past six years. This work has involved two main areas of practical
application: driver behaviour and railway infrastructure workers, particularly shunters. These
studies have begun to provide preliminary answers to the following important questions:
• What forms do violations take?

• Who is most likely to commit them?
• How and why do violations occur?
• What are the most effective counter-measures?
• How do violations lead to accidents?
Answers to these questions are generalisable beyond the driving or shunting contexts. They
have practical relevance for the wide range of hazardous activities involved in oil exploration
and production.
This research has also made it clear that violating safe operating procedures is not just a
question of the recklessness or carelessness of those at the sharp end. The factors leading
to deliberate non-compliance extend well beyond the psychology of the individual in direct
contact with the hazards. They also include such organisational issues as:
• the nature of the workplace,

• the quality of tools and equipment,
• whether or not supervisors and managers turn a "blind eye" in
order to get the job done,
• the quality of the rules, regulations and procedures,
• the system's overall safety culture.
If there is a single message to be communicated here, it is that everyone in an organisation,

from the board room to the sharp end, bears some responsibility for the commission of
3
violations. It also follows that everyone in the company has a part to play in minimising their
occurrence.
2. Introducing violations and procedures
2.1. Errors and violations
Violations are deviations from safe operating procedures. They are usually deliberate, but
can be unintended or even unknowing. They can also be mistaken in the sense that
deliberate violations may bring about consequences other than those intended, as at
Chernobyl. The distinction between errors and violations is often blurred. The main points of
difference between them are summarised in Table 1.
Table 1. Summarising the main differences between errors and violations.
Errors Violations
Stem mainly from informational factors: incorrect Stem mainly from motivational factors. Shaped
or incomplete knowledge, either in the head or in by attitudes, beliefs, social norms and
the world. organisational culture
They are unintended. Violations usually involve deliberate deviations

from rules, regulations and safe operating
procedures.
They can be explained by reference to how Violations can only be understood in a social
individuals handle information. context.
The likelihood of mistakes occurring can be Violations can only be reduced by changing
reduced by improving the relevant information: attitudes, beliefs, social norms and
training, roadside signs, the driver-vehicle organisational cultures that tacitly condone non-
interface, etc. compliance.
Errors can occur in any situation. They need not, Violations, by definition, bring their perpetrators
of themselves, incur risk. into areas of greater risk.
Although our principal concern here is with violations, it is impossible to treat them in isolation
from errors for several reasons.
• Together, errors and violations comprise the broad category of unsafe

acts.
• Errors and violations have several causal factors in common. This is

particularly true of organisational factors, and to a lesser extent of
situational and personal factors, as will be described in Chapter 8.
• Error and violation types can both be classified according to whether the
individual was operating at the skill-based, rule-based or knowledge-
based levels of performance. This taxonomy will be described in Chapter
3.
• Accidents are frequently associated with particular combinations of

violations and errors.
4
2.2. Safe operating procedures
Safe operating procedures are written to shape people's behaviour so as to minimise their
risk of coming into damaging contact with workplace hazards. As such, they form part of the
system's defences against accidents. System defences are of two kinds.
• "Hard" defences provided by fail-safe designs, engineered safety features

and mechanical or chemical barriers.
• "Soft" defences provided by procedures, rules, regulations, specific safety

instructions and training. "Soft" defences are more easily circumvented
than "hard" defences and thus constitute a major challenge to any safety
management system.
Procedures are continually being amended to cover changed working conditions, new
equipment and, most particularly, to prohibit actions that have been implicated in some
recent accident or incident. Over time, these procedural changes (particularly those triggered
by past accidents) become increasingly restrictive (see Figure 1). Yet the actions necessary
to get the job done under less than ideal conditions often extend beyond these permitted
behavioural boundaries.
Ironically, then, one of the effects of continually tightening up procedures in order to improve
system safety is to increase the likelihood of violations being committed. The scope of
permitted action shrinks to such an extent that the procedures are either violated routinely or
on those occasions when operational necessity demands it. In either case, they are often
regarded as unworkable by those whose behaviour they are supposed to govern. Whereas
errors arise from various kinds of informational under-specification (see Reason, 1990), many
violations are prompted by procedural over-specification.
History of
system
Scope of regulated
action Continuous
updating
of procedures
to avoid
recurrence
of past
accidents
and
incidents
Actions sometimes necessary

to get the job done
Figure 1. Showing the diminishing scope of action as procedures are modified to minimise
the recurrence of past incidents and accidents
5
3. Performance levels
Rasmussen's performance levels -- skill-based, rule-based and knowledge-based -- have

been used as a framework to classify error types (Reason, 1990). The same framework can
also be used to discriminate different types of violations. The three performance levels are
summarised below.
• At the skill-based level, we carry out routine, highly-practised tasks in a

largely automatic fashion, except for occasional conscious checks on
progress. This is what people are very good at for most of the time.
• We switch to the rule-based level when we notice a need to modify our

largely preprogrammed behaviour. We have to take account of some
change in the situation. This problem is often one that we have
encountered before and for which we have some prepackaged solution
(i.e., one developed by training and/or experience). It is called the rule-
based level because we apply stored rules of the kind: If (this situation)
then do (these actions). In applying these stored solutions we operate
very largely by automatic pattern-matching: we automatically match the
signs and symptoms of the problem to some stored solution. We may
then use conscious thinking to check whether or not this solution is
appropriate.
• The knowledge-based level is something we come to very reluctantly.

Only when we have repeatedly failed to find a solution using known
methods do we resort to the slow, effortful and highly error-prone
business of thinking things through on the spot. Given time and the
freedom to explore the situation with trial and error learning, we can often
produce good solutions. But people are not usually at their best in an
emergency -- though there are some notable exceptions. Quite often, our
knowledge of the problem situation is patchy, inaccurate, or both.
Consciousness is very limited in its capacity to hold information, usually
not more than two or three distinct items at a time. It also behaves like a
leaky sieve, forgetting things as we turn our attention from one aspect of
the problem to another. In addition, we can be plain scared, and fear (like
other strong emotions) has a way of replacing reasoned action with
"knee jerk" or over-learned responses.
A convenient way of representing the characteristics of the three performance levels is as

locations within an 'activity space' defined by two dimensions: control mode and situation.
This is shown in Figure 2.
6
Control modes
Mainly Conscious Mainly
Situations
conscious and automatic automatic
Routine
Expected Skill-based
performance
Familiar or
trained-for Rule-based
problems performance
Novel, Knowledge-
difficult or based
dangerous performance
problems
Figure 2. Locating the performance levels in the activity space.
Three further points need to made about the activity space.
• Running upwards across the diagonal from bottom left to top right is a
skill or expertise continuum. By definition, performance at the
knowledge-based level implies an absence of relevant expertise.
Expertise at the rule-based level means the possession of a potentially
large number of stored solutions to recurrent problems. The skill-based
level involves the largely non-conscious control of action sequences that
are run off in a pre-programmed fashion.
• As situations become more problematic (from top to bottom of the

space), so emotional factors are likely to play a greater and possibly
more disruptive part.
• The experience of mental effort will increase as activities move from right
to left across the space. This has important implications for both errors
and violations. The principle of least effort is one of the overriding
features of mental functioning.
7
4. Classifying violations
Case and field study observations suggest that violations can be grouped into four
categories: routine violations, optimising violations, situational violations and exceptional
violations. The relationships of these to both performance levels and error types is
summarised below in Table 2.
Table 2. Relating both error types and violation types to Rasmussen's performance levels.
Performance levels Error types Violation types
Skill-based (SB) Slips and lapses Routine violations

Optimising violations
Rule-based (RB) RB mistakes Situational violations
Knowledge-based (KB) KB mistakes Exceptional violations
An important feature of the performance level framework is that it carries implications for both
procedures and violations. Neither can be considered meaningfully in isolation from the other.
4.1. Skill-based violations
Violations at the SB level form part of the individual's repertoire of skilled actions. They often
involve corner-cutting (i.e., following the path of least effort between two task-related points).
Such routine violations are promoted by a relatively indifferent environment. That is, one that
rarely punishes violations or rewards compliance.
In many instances, such as speeding on the roads, a violation may have no deliberate
intentional component. A person may be unaware that he or she is committing a violation.
Such unwitting deviations are violations in name only. This unawareness can take two forms:
unawareness of the rule, or unawareness of the deviation. Neither constitutes an adequate
legal defence, but they are psychologically distinct categories.
There is little need to proceduralise activities at the skill-based level. For the most part,
actions are governed by stored motor programs whose details are in any case beyond verbal
control or recall. Where procedures do cover activities at this level, they tend to take the form
of general exhortations (e.g., Care should exercised when... etc.). There is little point, for
example, in writing procedures to cover the way a skilled tradesman uses a screwdriver.
Optimising violations feature large at the SB level. This category acknowledges that human
action serves a variety of goals, and that some of these are unrelated to the purely functional
aspects of the task. Thus, a driver's functional goal is to get from A to B, but in the process
he or she can (either knowingly or unknowingly) optimise the "joy of speed" or indulge
aggressive instincts. Similarly, long haul pilots and mariners may deviate from safe operating
procedures in order to alleviate boredom. Tendencies to optimise non-functional goals can
become part of an individual's performance style. They are also characteristic of particular
demographic groups, such as young men.
4.2. Rule-based violations
Safety procedures, rules and regulations are written primarily to control behaviour in
problematic or risky situations, and are thus most abundant at the RB level. In the initial
stages of particular system or technology, the procedures may simply provide instructions on
how to carry out the necessary tasks and how to deal with foreseeable hazards. But
procedures are continuously being amended to incorporate the lessons learned in past
8
incidents and accidents. Such modifications usually proscribe particular actions known to
have been implicated in a particular accident or incident scenario.
The upshot is that the scope of allowable action gradually diminishes as the system or
technology matures. However, the range of actions necessary to get jobs done within current
operational and commercial constraints may not diminish. This creates the conditions
necessary for situational violations. These are problems for which violations offer possible or,
in some cases (e.g., Chernobyl), the only solutions.
The character of situational violations can be illustrated with an example drawn from railway
shunting. The British Rail Rule Book prohibits shunters from remaining between wagons
during easing-up; that is, when a set of wagons are being propelled by a pilot engine towards
some stationary wagons to which they will be attached. Only when the wagons are stopped
can the shunter get down between them to make the necessary coupling. On some
occasions, however, the shackle for connecting the wagons is too short to be coupled when
the buffers are at their full extension. The job can only be done when they are momentarily
compressed as the wagons first come into contact. Thus, the only way to join these particular
wagons is by remaining between them during the easing-up process.
This example illustrates an important point about situational violations: they are commonly
provoked by inadequacies of the site, tools or equipment. Moreover, the actions prompted by
these latent failures often involve the additional factor of satisfying the least effort principle.
We will return to the factors contributing to shunters' violations in Chapter 7.
RB violations are likely to be more deliberate than SB violations. However, just as mistakes
are intentional actions carried out in the belief that they will achieve their desired ends, so
situational violations tend to be deliberate acts carried out in the belief that they will not result
in bad consequences. As Battmann and Klumb (1993) have pointed out, these violations are
shaped by cost-benefit tradeoffs, where the benefits of non-compliance are seen as
outweighing the possible costs (see Chapter 5).
Such assessments can be mistaken. Thus, situational violations can involve both mistakes
and procedural deviations, a class of violation that we might call "misventions" (a blend of
mistaken circumventions).
4.3. Knowledge-based violations
By definition, activities at the KB level take place in atypical or novel circumstances for which
there is unlikely to be any specific training or procedural guidance. Trainers and procedure
writers can only address known or foreseeable situations.
The Chernobyl disaster provides perhaps the best documented account of exceptional
violations. The experimental plan already demanded a situational violation, namely operating
without the emergency core cooling system for the purpose of testing the voltage generators.
The sequence of active human failures began with a slip (the undershooting of the 25 per
cent power level) and then proceeded on the basis of a misvention (continuing the tests while
the RBMK reactor was operating at considerably less than the minimum 20 per cent power
level, thus making it liable to positive void coefficient). Thereafter followed a series of
exceptional violations by which the operators successively shut off safety systems, making
the explosions inevitable. They did so in apparent ignorance of the basic physics of the plant
and in the hope of completing the tests in an already diminished window of opportunity.
Problems encountered at the KB level do not have to be novel in the sense that the surface
of Mars would be novel to some future astronaut. Quite often they involve the unexpected
occurrence of a rare but trained-for situation, or an unlikely combination of individually familiar
circumstances.
9
Consider the following example: a pair of engineers are inspecting an oil pipeline. One of
them jumps down into an inspection pit and is overcome by deadly hydrogen sulphide fumes.
His companion, although trained to cope with such a situation (i.e., to radio for help and stay
out of the pit), obeys a primitive impulse and jumps down to help his partner, whereupon he
too is overcome.
The situation, although covered by procedures and training, had never been met before by
this person in reality. The individual may have been trained to handle such a situation, but
nothing had prepared him for the emotions that were actually felt on seeing his colleague in
desperate need of help. It was the presence of these strong feelings that made the situation
novel
This illustrates another point about exceptional violations: they often involve the transgression
of general survival rules rather than specific procedures. The gut impulse to help another
person in danger is frequently stronger than the dictates of training or common sense. The
survivors of such exceptional violations are often treated as heroes, which is hardly an
effective deterrent.
4.4. Transitions from KB to RB to SB
The first time a shunter violates in the easing-up situation (described above), it is likely to be
because he perceives a new problem (e.g., the shackle is too short and the wagons keep
moving) that he solves by going in between while the wagons are closing up.
But every time this situation recurs, he is likely to do the same thing. This is partly because
he has chanced upon an easier way of working, but also because going in-between now
becomes the preferred solution to all similar problems. Thus, a KB violation now becomes a
RB violation.
Later, he is likely to remain between whether the situation calls for it or not, since it has now
become a routine violation leading to a quicker (though more dangerous) way of working.
10
5. The behavioural economics of violating
The theory of behavioural economics provides useful way of considering the pluses and
minuses of violations (Battmann & Klumb, 1993). The basic assumptions of behavioural
economics can be summarised as follows:
• People strive to optimise their behavioural efficiency within the limits

defined by internal and external constraints.
• The finite human resources available to cope with tasks are the "money" of
behavioural economics. These can be either internal resources
(knowledge, skills, ability, time, energy) or external ones (tools, fellow
workers, plant, etc.).
• People invest limited resources (i.e., learning a skill) in the hope of

achieving resource gains (i.e., the saving of subsequent time and effort) in
the future. Optimising means achieving the greatest gains for the smallest
investment of resources.
• All human actions are constrained, either by internal factors (physical,

physiological and psychological limitations) or by external ones. The latter
may be either "hard" (engineered boundaries) or "soft" (rules, regulations
and procedures).
• Some constraints, like physical barriers and the laws of nature, cannot be
overriden. Others, like safe operating procedures, are optional and thus
open to violations.
In deciding whether or not to violate a particular rule or procedure, an individual's choice (it is
argued) is determined not so much by moral considerations as by behavioural economics.
Will the benefits of non-compliance outweigh the possible costs? Let us consider what these
benefits and costs might be within the safety context.
The benefits of violating depend very much upon the dominant level of performance. At the
skill-based level, the advantages are likely to be an easier way of working and the saving of
time and effort. They might also include some emotional payoffs, such as a thrill, "kicks",
macho self-regard, or the alleviation of boredom.
At the rule-based level, the benefits could quite simply be that violating affords the only way
of getting the job done. Here, the higher-level rule of 'production first' (or even the imperative
of economic survival) overrides the local workplace rule of 'safety first".
The benefits at the knowledge-based level are harder to characterise because they are, by
definition, novel and unanticipated circumstances. In the example given earlier of the person
rushing to help a colleague overcome by toxic gas, the hazards are real and apparent, but
the basic human urge to help a friend overcomes caution or fear.
At all three levels of performance, however, the primary costs of violating are likely to be
much the same. They include death and/or injury (to self or others), costly damage to assets
and/or environment, and various kinds of sanctions and punishments. The perceived
likelihood of these bad outcomes will be shaped by the proximity and severity of the hazards,
and by (often flawed) judgements of risk.
Even this simple analysis makes it clear that the positive and negative payoffs of violating are
unevenly balanced, at least at the skill-based and rule-based levels of performance. The
benefits are immediate and obvious. The costs have a low probability of being realised and
are remote from most people's everyday experience. The instant benefits are a direct
reinforcer of the violating actions, while the costs are, for the most part, only a remote
11
possibility. And as we shall see later, the perceived remoteness of the negative outcomes is
further sustained by a wide range of beliefs and attitudes.
Perceived
benefits
of
violating
Perceived costs of violating
Figure 3. Expressing behavioural economics in a graphical form. The circles

represent contemplated violations. Where these actions fall into the shaded area,
in which the benefits exceed the costs, they are likely to be carried out. Where
they fall below the diagonal, these contemplated actions are likely to be rejected,
leading to compliance.
Figure 3 shows the essentials of behavioural economics in a graphical form. However, this
picture presumes that the cost-benefit axes carry equal perceived weights (i.e., that the
scales are evenly balanced). But, to the routine violator, the reality is more likely to be
something akin to that shown in Figure 4, where experience has clearly shown that violations
are more likely to bring benefits rather than costs.
Perceived
benefits
of
violating
Perceived costs of violating
Figure 4. Where the perceived benefits of non-compliant actions clearly exceed the possible
costs.
The actions proscribed by procedures are usually ones that have been implicated in past
accidents. But they were rarely if ever the sole causes of those accidents. Rather, they
formed part of a network of interacting causes, so that their bad outcomes were determined
by a number of other co-occurring factors. These other factors hardly ever recur in exactly
the same way, so that the mere repetition of the proscribed act does not of itself achieve the
bad outcome.
Other reasons for this imbalance have to do with the way people perceive the relative costs
and benefits of a particular violation. In addition to the obvious fact that most workplace
12
violations of safe operating procedures do not lead to bad consequences, there are a number
of psychological factors at work to make people optimistic about the outcomes of their
actions. These are discussed in the next chapter.
The theory of behavioural economics helps us to see what must be done to achieve greater
workplace compliance with safe operating procedures. Ideally, we should manipulate the
personal, situational and organisational factors that shape the perceptions of costs and
benefits so as to reverse the balance shown in Figure 4.
But we need to go further than this. What should be stressed is not so much the costs of
violating as the benefits of compliance. It is better to accentuate the positives rather than
trying to emphasise the often unlikely negatives. In other words, we should strive for
something like that shown in Figure 5.
Perceived
benefits
of
compliance
Perceived costs of compliance
Figure 5 Accentuating the positive.
At present, many procedures fail to ensure compliance because they conflict with the laws of
behavioural economics. Reversing this state of affairs means writing procedures that lead
directly not only to a safer, but also to a more satisfying and more efficient way of working.
Reducing situational violations means designing and equipping workplaces so that violating
does not offer the only way of getting the job done. To the extent that these ideal procedures
do not currently exist, the fault must lie with management rather than with the individual.
People can be motivated in two ways: by extrinsic motivation and by intrinsic motivation.
Extrinsic motivators are the rewards and sanctions imposed by the organisation. They are
there to persuade people to do things they would not naturally do, either because they do not
know how or because they do not want to work in this way. Thus extrinsic motivators always
create a conflict between what people would naturally do and what they should do.
Intrinsic motivators are those things that cause the person to carry out the desired activity
without conflict. They do them because they want to, because they are seen to be the best
way and because doing things the right way makes them feel good. There is a great deal of
evidence to show that intrinsic motivation is associated with a better quality of work, higher
productivity, greater creativity and enhanced self-esteem. We will examine the factors known
to promote or decrease intrinsic motivation in Chapter 9.
13
6. Personal factors influencing the perception of costs and benefits
The roads make an excellent natural laboratory for studying violations. Few if any drivers are
wholly compliant with the traffic regulations. Although there is strong evidence to show that
violations are implicated in traffic accidents, most of them incur no penalty. On the contrary,
they usually confer some advantage. As a result, violating behaviour becomes an habitual
part of the driver's repertoire of actions.
6.1. Common traffic violations
Below are listed the most frequently occurring violations observed on British roads. The
figures in parentheses show the percentage of individuals seen violating in the Manchester
driver behaviour studies. The rank ordering of these aberrant behaviours remained fairly
constant across different observational sites.
• Changing lanes without indicating (80%)

• Driving in excess of the speed limit (75%)
• Driving on the crown of the road unnecessarily (47%)
• Driving too close to vehicle ahead (24%)
• Shooting amber traffic or pedestrian lights (7%)
6.2. Age and gender
The Manchester research team has had several opportunities to establish the demographic
and psychological characteristics of those most likely to commit violations and dangerous
mistakes (Reason, Manstead, Stradling, Parker and Baxter, 1991). The most consistent
findings are summarised below.
Violating drivers are:

• young
• male
• have a high opinion of themselves as drivers (relative to others)
• drive a relatively high annual mileage
• are not particularly error prone
• are more likely to have been involved in 2 or more accidents
during the previous three years
• are significantly less constrained by normative influences (i.e., by
the people whose opinions they value) and by negative beliefs
about outcomes (i.e., they do not think their violations will have
bad outcomes -- the advantages of violating may be seen as
outweighing the possible costs).
6.3. Violations and road accidents
There is now a wealth of evidence to show that violations are much more likely to be
implicated in accident causation than errors alone. Below are some of the research findings
supporting this assertion.
Accident histories together with (self-reported) error and violation scores were obtained for a
large group of drivers (Reason, et al., 1991). High accident-involved people were
characterised by high violation scores, but by only average error scores (see Figure 6).
These drivers (who, for the most part, rated themselves as above average in driving skills)
appear to get themselves into situations they cannot always "drive their way out of". In-depth
14
interviews indicated that these people did not rate the consequences of risky manoeuvres as
seriously as others. They also felt more social pressures (from peers) to take these risks.
High accident respondents: Violation and error factor scores
4
Violation factor scores
-1
-2
-3 -2 -1 0 1 2 3
Error factor scores
Figure 6. Violation and error factor scores on the Driver Behaviour Questionnaire for a group
of high-accident respondents. Notice that this group has high violation scores but only
average error scores.
Statistical analyses of the scores on the Manchester group's Driver Behaviour Questionnaire
show that those obtaining high violation scores are over 40 per cent more likely to be
involved in active accidents (where the driver's vehicle is the hitter) than others (Parker,
West, Stradling and Manstead, 1993). When the influences of mileage, age, sex and years of
experience are removed, this figure drops to 15 per cent. But it is still a very significant
difference. Interestingly, high violators are also 36 per cent more likely to be involved in
passive accidents (where they are the ones hit), and 20 per cent more likely when the
demographic factors are partialled out. This involvement in passive accidents may be due to
infringements placing the violator's vehicle in situations where other drivers do not expect
them to be.
In a recent prospective study, motor cyclists were first assessed for error and violating
tendencies, using a self-report questionnaire. Twelve months later, they were interviewed
again to establish the extent to which they had been involved in road accidents during the
intervening period. The best prediction of these accident experiences was obtained from the
prior violation scores.
6.4. Why do people violate on the roads?
Given the very close relationships between violating and young males, it is tempting to say
that road traffic infringements are directly linked to an excess of testosterone. It is in the
nature of young men to bend the rules and to probe the established boundaries. Young
males have rude health, quick reflexes and are at the peak of their physical abilities, all of
which cry out to be tested to the limits.
Fortunately -- at least in the context of road transport -- the psychological and physical
pressures to violate diminish fairly rapidly with advancing years. In part, this increased
compliance is associated with a growing awareness of one's own mortality, morbidity,
15
vulnerability and general frailty in the face of dangerous hazards, not to mention increased
responsibilities and family ties.
Equally, or perhaps even more importantly (in view of the evidence discussed later), age-
related compliance is also due the fact that the middle-aged and the elderly have different
reference groups (people whose opinions they value) to the young, and that these more
mature "significant others" do not, in general, condone violations. The same factor probably
also plays a large part in the gender differences: violating is not something that other women
are especially likely to value or admire.
In any case, putting it all down to testosterone does not get us very far, since we have no
socially acceptable way of doing anything about it. So we have to ask more manageable
questions. In particular, what are the attitudes, beliefs, group norms and situational factors
that promote driving violations? Some of these, at least, we can change, albeit with difficulty.
The research on driving violations suggests that non-compliance is directly related to a

number of potentially dangerous beliefs or illusions. Some of the more important of these are
discussed briefly below.
• Illusion of control: Violators overestimate the extent to which they can

govern the outcome of risky situations. Paradoxically, they also use the
reverse of this belief in certain circumstances -- such as speeding --
where they feel that their own behaviour is merely conforming to the local
traffic patterns.
• Illusion of invulnerability: Violators underestimate the chances that their

rule bending will lead to bad outcomes. Skill, they believe, will always
overcome hazard. In addition, young males do not see themselves as
the likely victims of other people's bad behaviour. In a recent study,
young men were asked to judge the likelihood that they would be the
victims of street crimes relative to other demographic groups. They made
a sevenfold underestimate of their actual chances of being a victim of
street crime, where they are in fact the demographic group at greatest
risk. Similar tendencies are likely to operate when they are driving.
• Illusion of superiority: This comes in two forms. First, violators believe

themselves to be more skilled than other drivers. Second, they do not
regard their own tendencies to violate as being worse than other drivers.
Other important factors include:
• Aggression and other macho tendencies: Driving a vehicle provides two

things not usually available when dealing with others: a dangerous
"weapon" and a degree of anonymity. Together they are a heady
combination, particularly if one is a competitive young male (automobile
= autonomy + mobility). Many dangerous violations involve attempts to
"sanction" other road users who have given affront, either real or
imagined. This involves pursuits, cutting up and driving at a threateningly
close distance to the "target" vehicle ahead.
• I can't help myself: Violators may often feel that the temptation to bend
the traffic rules is irresistible.
• There's nothing wrong with it: Violators do not see their infringements as
being wrong or dangerous. For example, they rate their speeding
behaviour as less annoying, less serious and less risky than do more
law-abiding drivers.
• Everyone does it: Violators often explain their behaviour by saying that
they are just doing what everyone else does. This is also called "false
16
consensus". High violators overestimate the proportion of other drivers

who also violate.
• They really expect us to do it: Drivers working for a company often feel
themselves to be in a double bind. They are told not to break the rules,
but they are also expected to get the job done quickly. Many resolve this
conflict by seeing management's insistence on their compliance as
hypocritical: "They'll turn a blind eye so long as the job gets done quickly,
but we expect little mercy if our violations cause an accident."
6.5. Personality factors
The decision to violate is a function of many factors. Some of these relate to beliefs and
attitudes (shaped by age and gender), some to the nature of the situation (as will be
discussed later) and some must depend upon the characteristic way an individual reacts to a
wide variety of situations. In other words, violating behaviour is shaped in part by personality.
Traits and types are relatively enduring features of the individual that colour his or her
behaviour across a wide gamut of circumstances. They are the tendencies that a person
carries from one situation to another. Some psychologists have argued that these
dispositional characteristics are determined mainly by genetic factors and are evident
regardless of the situation. Others have placed more emphasis on the situational rather than
the constitutional determinants of behaviour.
The debate continues to rage, but there is little doubt that measures of personality
characteristics such as extraversion-introversion, stability-instability (neuroticism), external
versus internal locus of control, and the like, allow one to make reasonable predictions about
a person's behaviour across a large range of situations. Hence, personality features cannot
be ignored in our quest for the roots of violating behaviour. Below, we will consider four
relevant aspects of personality: accident proneness, unstable extraversion, compliance and
the locus of control.
6.5.1. Accident proneness
Almost everyone knows a nebbisch, the Yiddish word for someone who manages to be
underneath whenever a brick falls and who provides a steady source of income for
orthopaedic surgeons. The belief that some people are especially prone to attracting
misfortune is deeply rooted in folklore and mythology. The first documented case of accident-
repeating was probably Job. The Book of Job illustrates well the common tendency to blame
accident liability upon some characteristic of the victim.
As an explanation of repeated accidents in certain people, accident proneness refers to a set

of personality characteristics, possessed by these individuals, that causes them to have
mishaps regardless of the environmental circumstances. It is this strong use of the term that
has caused all the controversy.
The idea of accident proneness was also born at a time when engineers were finding it
increasingly difficult to reduce industrial accidents any further by conventional safeguards.
Consequently, they were very much attracted to the idea that people rather than machines
were primarily responsible -- or, to be more precise, accident-prone people.
If one accepted the possibility that a few people had most of the accidents because they
were afflicted with an 'accident-prone' personality, the next step was obvious. Make a
detailed study of accident repeaters, find the common personality traits, and the solution is at
hand. Simply put all workers and applicants through a battery of personality tests, screen out
all the people whose profiles coincide with the typical accident-prone personality and you
have largely eliminated the residual accident problem.
17
As it turned out, there was no such thing as a 'typical' accident-prone person. Accident-
repeaters showed a wide range of characteristics. Furthermore, examination of accident-
repeaters over a lengthy period showed that they were members of a club that was
continuously changing its membership.
A compromise view, and one that accommodates the often temporary nature of accident-
repeating, is Schulzinger's (1956) accident syndrome theory.
Schulzinger was struck by the way certain people have repeated accidents, clustered in
specific time periods. He also noted (from his sample 20,000 accident patients) that about
50% of those having repeated accidents tend to do so during identical hours of the day, or on
particular days of the week or month. He wrote:
In the course of a lifetime almost any normal individual under

emotional stress may become temporarily "accident-prone" and
may suffer a series of accidents in fairly rapid succession. Most
persons, however, find solutions to their problems, develop
defences against their emotional conflicts, and drop out of the
highly "accident-prone" group after hours, days, weeks or
months. Some individuals may remain highly "accident-prone"
throughout life... The latter are the truly "accident-prone"
individuals. They contribute, however, only a relatively small
percentage of all the accidents.
If we were to pinpoint the main groups of "accident-makers" they

would be found among the young, the male and maladjusted;
with unbridled, misdirected aggressiveness a uniting common
denominator.
When such people experience a trigger episode, involving a close encounter with a
hazard, their (usually) temporary "lack of mental balance" causes them to react
inappropriately, making them more liable to sustain injury.
For Schulzinger, a physician, these episodes of accident liability are akin to a disease:
hence the term "accident syndrome". Like other diseases, this syndrome is amenable
to treatment.
Yet another approach, not necessarily incompatible with the above, focuses upon the
style with which a person performs a particular job. Someone who drives dangerously,
for example, need not exhibit the same behaviour when performing another task.
Driving style is shaped by the quality of training, by the habits -- good or bad --
acquired over the years, and the way in which people react to the stresses peculiar to
driving.
6.5.2. Unstable extraverts
Roger Green (1992), a psychologist concerned with investigating aircraft crashes, has noted
a high proportion of unstable extraverts among those air crew involved in military and civil
aircraft accidents. This personality type is based upon a modern reworking of the old doctrine
of the humours where people were distinguished according to which of the four bodily
humours (blood, phlegm, yellow bile, black bile) was dominant (see Figure 7).
18
Unstable
moody touchy
anxious restless
rigid aggressive
sober excitable
pessimistic changeable
reserved impulsive
unsociable optimistic
quiet active
Introvert Extravert
passive sociable
careful outgoing
thoughtful talkative
peaceful responsive
controlled easygoing
reliable lively
even-tempered carefree
calm leadership
Stable
Figure 7. The trait characteristics of stability-instability and extraversion-introversion. The top

left quadrant corresponds to the old melancholic personality. The bottom left to the
phlegmatic personality, the top right to the choleric personality and the bottom right to the
sanguine personality
It is clear that the traits described in the top right quadrant, the unstable extravert, are directly
related to tendencies to violate and to engage in dangerous behaviour. But it is not that
simple. Such tendencies contribute only a small part to predicting the way a person will
behave across a variety of situations. In addition, scores on both both axes (stability-
instability, extraversion-introversion) are normally distributed, meaning that only relatively few
people occupy these extreme positions.
6.5.3. Compliance
People and nationalities appear to differ in the extent to which they are prepared to follow the
rules. A recent study at Manchester University (Free, 1993) investigated the psychological
bases of compliance, using a questionnaire. Three factors were identified, accounting for
42% of the variance.
Factor 1: Unthinking compliance
The highest loading questionnaire items were:
• If you don't follow the rules you should expect to be punished.

• People who disobey the rules are just being awkward and making
life hard for themselves.
• I would not question the rules if they were written by experts.
• I am in favour of very strict enforcement of all laws no matter
what the consequences.
19
Factor 2: Pragmatic rule-bending
The highest loading items were:
• An experienced worker is justified in not doing the job exactly to

the book.
• A really skilled worker is one who knows which rules to bend so
as to get the job done more efficiently.
• People who mindlessly follow the rules are just covering
themselves.
Factor 3: Perceived legitimacy
Here, compliance or deviation depended upon the perceived value of the

rule or the perceived qualifications of the rule-maker. The highest loading
items were:
• I would not obey rules enforced by a person who does not

deserve their position of power.
• I don't obey rules unless I agree with them.
• If a manager asked me to do something which I did not agree
with, I would not do it.
These factors identify one personality-dependent reason for strict compliance ("rules must be
obeyed at all times without question") and two conditional reasons for non-compliance:
"skilled workers know how to (or must) bend the rules to get the job done," and "bad rules
should not be obeyed," where "badness" may either be a property of the rule or of the rule-
giver.
The other finding of note was that people in lower occupational groupings (i.e., supervised
skilled workers and supervised unskilled workers) scored significantly higher on compliance
than did those in higher occupational categories (i.e., senior managers, directors or
professionals). See also Section 7.4.
6.5.4. Locus of control
People vary in the degree to which they believe they have control over their actions and in
the extent to which they accept personal responsibility for the outcomes. According to Rotter
(1966), such beliefs are a relatively enduring aspect of personality, the features of which are
defined below:
• Internal control refers to the perception of positive and/or negative events

as being a consequence of one's own actions and thereby under
personal control.
• External control relates to the perception of good and bad events as

being due to factors beyond one's control (i.e., luck, chance or divine
will).
People differ characteristically in the way they see the balance between internal and external
control of their actions. They also behave very differently in situations in which they perceive
outcomes as being due to their own skill and efforts or to factors outside their control. In
retrospect, they tend to attribute success to internal factors and failures to external ones.
This dimension takes on particular significance in dangerous or stressful situations. People's

safety and those of others will depend a great deal on whether the hazards and stresses are
seen to be controllable, or as lying in the hands of fate.
20
7. Situational factors influencing violations
The relatively solitary and enclosed nature of driving highlighted the influence of personal
factors upon violating behaviour. Other Manchester studies, particularly those investigating
the behaviour of railway shunters, have emphasised the significance of situational or
workplace factors (Free, 1993).
Ninety-one per cent of shunting fatalities arise from being caught between vehicles while
coupling or uncoupling (64%) or by being struck while walking on the line (27%). Both types
of accident involve violations of the British Rail Rule Book. What follows describes the main
findings of a series of Manchester studies designed to establish the reasons for these and
other shunting violations.
7.1. Violation frequency and perceived risk
Half the shunters in the Manchester region completed a survey in which they rated 40
shunting rules in regard to (a) the frequency with which each rule was violated, and (b) the
perceived riskiness of violating each rule.
Contrary to expectation, there was no inverse relationship between violation frequency and
perceived risk. Indeed, several of the violations rated as high risk were also rated as high
frequency. On being interviewed, the shunters indicated that the demands of the immediate
situation often required the commission of a violation in order to get the job done on time.
This study indicated that situational factors rather than judgements of riskiness were more
influential in determining whether or not a violation was committed.
7.2. Why shunters violate
Twleve rule violations, previously rated by shunters as being either high frequency or
associated with high risk, were used as the basis of a questionnaire study. Thirty-six shunters
were asked to read the description of each violation and then to choose up to five possible
reasons for violating from a list of 14 reasons, previously obtained from interviews with
shunters.
Time pressure, high workload and a quicker way of working featured among the reasons for
all rule violations. These were designated as general factors and excluded from the
subsequent analysis.
The remaining reasons clustered into four groups, each group being related to particular
rules. These are summarised below along with their associated rules. HF and LF indicate that
a rule was either high frequency or low frequency. HR and LR indicate high and low risk,
respectively.
Cluster 1: Competence
The reasons here were inexperience, laziness and the fact that management turns a blind
eye. Shunters saw these violations as being more the result of errors than deliberate non-
compliance. The associated rules are listed below.
• The shunter connects the brake pipes first before dealing with other
connections when coupling (LR, HF).
• The shunter works without wearing the high visibility clothing provided
(LR, HF).
21
• The shunter fails to look both ways before crossing the line and does not
take extra care when stepping out from behind a vehicle (HR, HF).
Cluster 2: Attitude
The reasons for violating were: "A skilled shunter can work this way." "It's a macho way to
work." "Management turns a blind eye." These were associated with high-frequency low-risk
violations, classified as routine violations. The actual violations are listed below.
• The shunter gets on and off the pilot engine while it is moving (HF, LR).
• Though not authorised to do so, the driver proceeds above the permitted
speed limit in the siding (HF, LR).
Cluster 3: Work conditions
These were high-frequency and high-risk violations, classified as situational violations. In

addition to inexperience, the reasons given for violating were: "Design of sidings make
violating necessary." "Rules can be impossible to work to." The actual violations were:
• Even though he has lost sight of the shunter, the driver does not stop
during a movement (HR, HF).
• Although practicable, the shunter does not walk in front of a movement
that is being propelled (HR, HF).
Cluster 4: Rare circumstances
These were low frequency and high risk violations, classified as exceptional violations.
Violations of these rules were not strongly associated with any of the reasons offered.
• The shunter fails to give a hand danger signal to the driver to instruct him
to remain stationary before going in between (HR, LF).
• The shunter remains in between vehicles and asks the driver to ease up.
(HR, LF).
• While working, the shunter goes under a stationary vehicle and crosses
the line less than 50 feet from a vehicle without making absolutely sure
that no movement is taking place (LF, HR).
Interestingly, the three violations for which no specific reasons were given (i.e., those
associated with Cluster 4) describe exactly those kinds of situations most commonly
associated with shunters' fatal accidents: being caught between vehicles and being struck by
vehicles while walking on the line. One plausible inference is that these are exceptional
violations, dictated by rare combinations of circumstances, that seem to implicate all three of
the specific violation-causing factors: competence, attitude and work conditions.
Unfortunately, when this rare combination of circumstances does occur, the chances of a
serious accident are high.
7.3. Predictors of shunting violations
In a third study (Free, 1993) shunters' attitudes to five violation scenarios incorporating some
of these different sub-types were examined. The first three scenarios each focused upon the
first three specific factors (Clusters 1-3 above). The fourth and fifth scenarios related to
circumstances known to be associated with fatal accidents (i.e., those in Cluster 4).
The study also looked at three factors known to contribute to behavioural intentions. These
were behavioural beliefs, motivation to comply with the perceived wishes of important others,
and perceived behavioural control. In addition, respondents were given the opportunity to
indicate which, if any, of a list of local factors provided, would make committing the violation
in question more likely.
22
23
The five scenarios are listed below:
1. You and the shunt driver have to get a train ready for departure. The job
involves propelling 8 wagons on to 6 wagons to make up the full train.
You stand at the stationary wagons and signal the driver to come
towards you. When necessary you signal the driver to stop. (A situational
violation within Cluster 3).
2. You have just completed a move. You get off the pilot and set the points
for the cabin road. You hold the points and the driver sets off. When he
is over the points, moving slowly, you catch him up and jump on the
engine steps. (A routine violation within Cluster 2.)
3. You need to speak to the driver of the loco that has just arrived in the
sidings. You cross the line behind the pilot, but do so without looking
both ways. (an erroneous violation within Cluster 1).
4. The driver propels a movement on to Road 4, where two vehicles are

waiting to be attached. He sees the shunter hold both arms above his
head to tell him to stop. He puts on the brakes immediately. He hears the
buffers come together, but there is no sign of the shunter. After a few
minutes he becomes concerned that the shunter has not given him
further instructions. He secures the train and gets out. He finds the
shunter trapped between the buffers.
5. The shunter remains in between the vehicles and asks the driver to ease
up. He is later found lying in the four foot, his hard hat on the ground
next to him.
Forty-five shunters took part in the study. Analysis showed that in the case of Scenario 1, a
situational violation, none of the behavioural beliefs correlated with intention to violate,
possibly because -- in this case -- tendencies to violate are more likely to be shaped by the
specific work situation than by the individual shunter's beliefs. However, there was a
correlation with perceived behavioural control, suggesting that if a shunter felt it was safe to
propel without walking in front of the movement, then he or she might do so. From the list of
other causal factors provided, those seen as contributing to the likelihood that the violation
would occur were condition of the sidings, bad weather and bad communication.
In Scenario 2, which depicted a routine violation, both behavioural beliefs and perceived
control correlated with behavioural intention. For this particular violation responses to the
behavioural belief items show that the shunters believe that skill offsets risks and the time
saved increased the benefits over the costs. Additional causal factors considered to be
important were bad weather, sidings in poor condition and tiredness.
In Scenario 3, an unintentional violation, neither behavioural beliefs nor control belief items
appeared to contribute to intention to violate. Error rather than violation was seen by the
shunters as the likely cause. The behaviour was thought to be more likely to occur when the
shunter is tired or in a bad mood, and in bad weather.
7.4. Comparing the compliance of staff and management
A questionnaire, incorporating both the compliance items (see Section 7.2.) and the violation
scenarios (see Section 7.3), was given to a large number of British Rail staff (Free, 1993).
These included both senior managers and line managers as well as most of the 'sharp end'
staff in that particular location. The results are summarised below.
24
• Sharp end staff scored more highly on strict (or unthinking) compliance
than did the managers. Staff serving longer than 30 years showed higher
strict compliance than did those who had served for a shorter period.
• New managers were more pragmatic in their approach to rules than older
managers, while long-serving workers tended to be more pragmatic than
new workers, particularly those who have worked on the railway between
9 and 30 years.
• Managers were more likely to think that violations occur because it

makes the job easier and because workers do not perceive the risks.
The workforce was more likely than the managers to see violations as
being associated with impractical safety procedures, saving time and
production pressures from supervisors and management.
In addition, the findings confirmed the existence of two basic forms of compliance: strict or
unthinking compliance and pragmatic or expedient compliance, where the decision to violate
depended upon either the specific situation or the perceived legitimacy and/or utility of the
rule.
25
8. Organisational factors influencing violations
8.1. Procedural failures
Procedures are one of a number of organisational control devices designed to direct safe and
efficient working. They are necessary because people change faster than jobs, and it cannot
be assumed that all workers are sufficiently trained, experienced, motivated or able to choose
the safest and most efficient way of working for themselves, at least at the outset.
Procedures thus comprise the accumulated craft wisdom of the organisation. This is usually
updated at intervals to incorporate the lessons learned from the most recent accidents, and is
expressed in both a presciptive and a proscriptive fashion. Procedures prescribe what should
be done and proscribe what should not be done (i.e., the British Rail Rule Book).
To understand how these procedural controls can fail, we need to view them in the context of
the other control modes available to those managing an enterprise, such as a Shell OpCo.
The four principal organisational controls are listed below.
• Administrative controls. These are rules, standards, regulations and

procedures. Their aim is to create working conditions in which people
behave in ways that optimise the achievement of organisational goals.
• Social controls. These emerge from interactions among members of work

groups to produce ways of acting and thinking that the group considers
legitimate. Such group norms need not always conform with those of the
parent organisation.
• Personal controls. These are the controls that people exert over their own
behaviour through intrinsic motivation and behavioural economics.
Personal controls are strongly influenced by situational factors and social
controls and, to a lesser extent, by administrative controls.
• Technical controls. These include automation and various engineered

features designed both to limit and to replace direct human participation
in the production process.
These various organisational controls interact with one another in complex and often self-
defeating ways. Many of the reasons why procedures fail -- in the sense that violations can
be the rule rather than the exception -- may be traced to poorly "tuned" or conflicting
applications of these organisational controls. Once again, the human performance levels (or
at least the skill-based and the rule-based levels) provide a useful means of classifying the
varieties of procedural failure.
8.1.1. Skill-based or routine violations
The existence of routine, habitual violations indicates a long-standing conflict between the
goals of the organisation and those of the individual or work group, In other words, they arise
from administrative-personal control conflicts and/or from conflicts between administrative
and social controls.
Such conflicts can occur for many reasons, but several of them can be subsumed under the
general heading of writer-user mismatch. Those who wrote the procedures had little or no
direct experience of performing the task in question, particularly under less than ideal
conditions. As a result, they create one or more of the following problems for the end-user:
• The required actions are not covered or ambiguously specified.
26
• They are ill-suited to the particular situation.

• They call for actions whose purpose is not clear.
• They are unnecessarily laborious.
• They conflict with the comfort and well-being of the user.
Other problems arise through lack of appropriate feedback. By definition, routine violations
pass unnoticed or uncorrected by supervisors. Violations go unpunished either by the system
or by incurring bad outcomes. Compliance goes unrewarded. The only things that get
rewarded, and hence stamped in as part of habitual behaviour, are the procedural deviations
that bring with them an easier way of working and, for some, the satisfaction of personal
rather than task goals.
More subtle problems arise from worker's perceptions of "those in authority". As shown
earlier, one of the factors affecting compliance is the degree of respect people feel for the
rule makers themselves. Procedural failures, such as those listed above, diminish
management's credibility in the eyes of the workforce. Bad or inapplicable rules encourage
violations by fostering contempt both for the rules and for the rule givers.
Another perceptual factor concerns how workers see the purpose of the procedures. Are they
there to protect the workforce, or to provide legal cover for the organisation in the event of an
accident caused by a violation? On the one hand, their violations can be condoned so long as
they get the job done. One the other, they know that they or their families will receive no
compensation should they be injured or killed as the result of a procedural violation. These
dual standards are unlikely to encourage either compliance or loyalty.
British Rail, among others, are now appreciating that rules and procedures written to govern
the actions of the less educated and more biddable workforce available in earlier times are
not appropriate for the more egalitarian present (Maidment, 1993). They are engaged in a
major rewriting of their procedures, a process that involves the active participation of those at
the sharp end. People are much more likely to comply with rules when they themselves had a
stake in formulating them.
There is a considerable amount of evidence (see Section 9.5) to show that external controls
have an adverse effect when applied to tasks that people are intrinsically motivated to
perform. This appears to be a Catch 22 situation. If a person is not intrinsically motivated to
do a particular job, the temptation is to employ external motivators, such as rewards and
punishments. They may work for a time, but they do not encourage people to become self-
motivated in the long term.
The more people are managed through external controls, the less likely they are either to
enjoy working or to take personal responsibility for their behaviour (see Section 9.5). This
does not mean that we should drop all external controls, but it indicates that they should only
be the minimum necessary to provide the structure and security for safe and efficient
working.
8.1.2. Ruled-based situational violations.
So far, we have emphasised procedural failures due to conflicts between administrative and
personal goals. But a large class of violations arises from clashes between production and
safety goals. People want to get the job done, but they are thwarted by rules that proscribe
the required actions, or by conditions that make procedures impossible to follow. Only
violating offers an immediate solution to these local problems.
The origins of situational violations are twofold. First, the procedures are insensitive to local
imperfections and therefore unworkable. Second, the workplaces are poorly designed or
inadequately equipped, demanding non-standard job practices. Both of these problems
require managerial rather than worker-targeted solutions. Organisational failure types such as
poor tools, inadequate maintenance, bad design, and the like are the common root causes of
many unsafe practices, as will be discussed below.
27
8.2. Organisational failures
The organisational origins of both errors and violations can be accommodated within the
same theoretical framework. These causal factors may be broken down into three categories
(see Figure 8).
• Personal factors relating to the states of mind and body of the individual
concerned.
• Situational factors relating to the task and/or environmental conditions.
• Organisational factors relating to systemic and managerial processes

affecting the company as a whole.
Situational Personal
error error Error
factors factors types
Organisational Situational Personal

factors factors factors
common to Erroneous
common to common to
both errors violations
both errors both errors
& violations & violations & violations
Situational Personal Violation

violation violation types
factors factors
Organisational Situational Personal Unsafe

factors factors factors acts
Figure 8 Summarising the causal factors for both errors and violations.
The theoretical framework in Figure 8 makes two important assertions.
• The first is that the direction of causality runs from organisational factors
to unsafe acts via the situational and personal factors. Organisational
factors create error- and violation-producing conditions within the
workplace and these, in turn, interact with personal factors to create the
unsafe acts.
•The second is that all organisational factors are common to both errors
and violations, but the influence of these common factors diminishes as
one moves from the organisational level to the situational level and then
to the level of the individual.
The Tripod-Delta toolkit (currently available in a number of operating companies) is

specifically designed to diagnose and rectify those organisational failure types most likely to
promote errors and violations in the workplace. Full details of this package can be found in
the three volumes of the Tripod Handbook (SIPM, 1993).
8.3. Cultural factors
28
Culture is a widely used but variously defined term. For our present purposes, the following
definition of culture by Uttal (1983) will serve as well as any.
Shared values (what is important) and beliefs (how things work) that interact
with an organisation's structures and control systems to produce behavioural
norms (the way we do things around here).
Ron Westrum (1993) at Eastern Michigan University has made an extensive study of
organisational safety cultures. He argues that it is necessary to have a culture "of conscious
inquiry." The key criterion for successful information flow in organisations is the following:
The organisation is able to make use of information, observations or ideas

wherever they exist within the system, without regard for the location of the
person or group having such information or ideas.
Organisations need "requisite imagination" -- a diversity of thinking and imagining that

matches the variety of possible accident scenarios. To make use of ideas, they have to be
noticed. This "noticing" process, according to Westrum, distinguishes three kinds of
organisational cultures: pathological, bureacratic and generative. Their characteristics are
summarised in Table 3.
Table 3. How different organisational cultures handle information
Pathological Bureaucratic Generative
Don't want to know May not find out Actively seek information
Messengers are shot Listened to if they arrive Mesengers are trained
Responsibility is shirked Responsibility is Responsibility is shared

compartmentalised
Failure is punished or Failures (incidents and Failures prompt far-reaching

covered up accidents) lead to local inquiries leading to
repairs. organisational reforms
New ideas are actively New ideas present problems New ideas are welcomed
crushed
In summary, bad cultures focus upon the perceived delinquency of the workforce and
respond by further "blaming and training", increasing sanctions and the writing of even more
procedures. These rules are prepared and delivered top-down without enlisting the help or
advice of those who actually do the jobs. Good cultures see their safety problems as existing
at all levels of the organisation and encourage the workforce to participate in wide-reaching
reforms.
29
9. Counter-measures
9.1. Theory of Planned Behaviour
In order to reduce violating behaviour, we first have to change the attitudes and beliefs that
trigger it. To do that, we need a model relating the factors involved, and the most widely used
one at present is the Theory of Planned Behaviour (TPB), summarised in Figure 9 (Parker,
Manstead, Stradling, Reason and Baxter, 1992).
Attitudes to
behaviour
Subjective Behavioural Behaviour

norms intentions
Perceived
behavioural
control
Figure 9.Theory of Planned Behaviour
TPB identifies three influences upon behavioural intentions:
• Attitudes to behaviour: These are the beliefs a person has regarding the
consequences of some behaviour. How do the perceived advantages of violating
balance out against the possible risks and penalties?
• Subjective norms: These are the views that some important reference group
(relatives, friends, etc.) might hold about your behaviour. Will they approve or
disapprove, and how much does the person want to be admired or respected by
these "close others"?
• Perceived behavioural control: How much control does the person feel that he or she
exercises over the violating behaviour? This factor is likely to be of considerable
importance in fatalistic cultures, particularly in regard to judgements about the
consequences of violations.
9.2. Attempts to change individual attitudes to behaviour
Most propaganda attempts (i.e., videos, posters, TV campaigns) to change safety attitudes
have focused on the grisly consequences of the unsafe behaviour: the mangled limbs, the
dead children, the grieving family, and so on. While such approaches do have the power to
shock, there is little evidence that they achieve lasting results. The most effective of them
follow the well-tried hell-fire preacher formula: first you frighten, then you show the way to
avoid the feared outcome.
The likely reasons for the disappointing results of these fear appeals have been touched
upon earlier. Those most likely to violate -- young men -- are immunised by their three
maladaptive beliefs: the illusions of control, invulnerability and superiority.
• "I can always drive myself out of trouble."
30
• "It couldn't happen to me"

• "I'm no worse than anyone else, and in any case I'm a better driver than
most."
In addition, the roads -- despite the accident figures -- are a relatively forgiving environment.
For the most part, compliance goes unrewarded and violations go unpunished. The violator's
daily experience is that violations bring advantage rather than grisly consequences.
9.3. The use of social controls
Current research suggests that one of the most powerful factors affecting people's attitudes
is what "significant other" people might think about them. We are social animals. We need
the approval, liking and respect of those we care about. If we become convinced that these
"significant others" will strongly disapprove of our planned actions, we are likely to think twice
before carrying out this behaviour. It does not mean that we will never transgress, but it is
likely to give us pause.
Below are some pieces of evidence that, collectively, provide strong encouragement for
considering the influence of social controls (subjective norms) as a way of reducing
violations.
9.3.1. Pioneering the group decision technique
During the Second World War, a German-American psychologist, Kurt Lewin, set out to
persuade American housewives to buy less attractive cuts of meat. He used a group decision
technique designed to change group norms rather than individual attitudes. The technique
was highly successful, and was later used to increase productivity in factory workers. This
work was not concerned with violations, but it revealed a powerful method for altering long-
established choice patterns and has been taken as a model for later attempts to eliminate
undesirable behaviours.
9.3.2. The Misumi studies
Lewin's methods were used in Japan in the early 1980s to reduce unsafe behaviour (Misumi,
1982). The first study targeted 45 bus drivers who had caused two or more accidents in the
preceding three years. The accident rate of this group was more than four times higher than
the average accident rate in the company. The drivers were put through a six-step procedure:
1. A preliminary one hour warm-up session, designed to ease tension.
2. The drivers were divided into four groups, each of whom held discussions
on problems in their work places.
3. A 20-minute general meeting in which the chairmen of the four groups

reported on their discussions. The results were combined into 10-item
report.
4. The four small groups then reviewed these items and divided them into
two groups: those they thought they could solve by themselves and
those they felt needed to be taken up with management. They then
discussed the problems they thought they could solve themselves for 20
minutes.
5. In a new plenary session, the group chairmen reported on these more

focused discussions.
31
6. The four groups then discussed the problems relating specifically to bus
accidents, and what they themselves should do to decrease the number
of accidents. At the end of this 40-minute period, each driver was given a
slip of paper and asked to write down what "you yourself have decided to
practice from tomorrow on." They were not required to show this to
anyone else. The slip of paper was intended solely as a personal
reminder of their promises.
In the 10-month period following the group discussions, there were 14 accidents among
these drivers compared to 70 in the 10-month period before. The rates for other drivers
increased during this period. In part, this could be explained by the well known effect of
"regression to the mean". But the reduction in accident rates for the drivers taking part in the
group meetings was much greater than the increase for those not involved in the study,
suggesting that the regression effect could explain only part of this reduction. Subsequently,
further developments of this technique were applied successfully in shipyards.
9.3.3. The Swedish Telecom studies
A modified version of the Japanese technique was used by Swedish psychologists to improve
driver safety among Svenska Televerket (Swedish Telecom) drivers, one of the largest users
of cars in Sweden (Brehmer, Gregersen & Moren, 1991). It differed from the Japanese work
in focusing not just upon accident-prone drivers, but involved all the drivers in a given work
place. The Swedes used a three-step procedure, each session lasting for around one hour.
1. Drivers met in small groups of 10-15 people all of whom came from the
same workplace. They began by discussing general safety-related
problems. The results were recorded by trained discussion leaders.
2. At their second meeting, the same groups went through a list of problems
they had uncovered in the first session. As in the Japanese study, the
problems were divided into two groups: those they felt they could fix
themselves and those that had to be referred to management. The latter
items were passed on to Telverket management.
3. In the third meeting, the groups concentrated upon the problems falling
within their power to solve and discussed how they could be tackled. At
the end of the session, each driver was asked to write down what he or
she was going to do about the safety problem. As before, they were not
required to show this to anyone else.
The technique was applied in 30 areas, each having 25-30 drivers. Another 40 areas were
used as controls (i.e., no discussion groups). This resulted in 850 discussion drivers and 943
controls. The groups were matched for all other important variables. Data were analysed for
three years prior to the discussions (pre-test) and for two years after (post-test). The accident
rates in the post-test discussion groups were about half the pre-test values (see Figure 10).
No differences were found for the controls.
32
Controls
Pretest
Discussion
Controls
Posttest
Discussion
0 0.05 0.1 0.15 0.2
Figure 10. Comparing accidents per 10,000 km for control and discussion groups
pretest and posttest
Interestingly, a questionnaire sent out after the discussions provided no explanation for the
observed reductions in accident rates. Only 12 per cent of the respondents considered that
their driving styles had changed as a result of the group discussions, and only 25 per cent
thought that they had any beneficial effects.
How can we explain this? The Swedish drivers already possessed a positive attitude to
safety, though -- since safety was rarely discussed among themselves -- they were not aware
of how other drivers felt. The value of the group discussions lay in making these group values
visible to all members of the driver groups. The second effect of the discussions was to link
the motivation to drive safely with actual decisions about how this could be achieved.
An important finding from this study is that people do not always understand the true causes
of the changes in their behaviour. There is research evidence to show that people will not
report the real reasons for a behaviour change when this conflicts with their ideas of what
constitutes an effective cause. Instead, they report their theories of why things changed.
9.3.4. The Manchester video study
The Manchester Driver Behaviour Research Group prepared a series of short videos
depicting a young man driving at 40 mph in a built-up suburban area (Parker & Stradling,
1993). The aim was to compare the relative persuasiveness of their various messages, using
drivers as judges. The video producing the most anti-speeding thoughts was the one in which
the driver's female partner, male friend and young son each expressed negative feelings
about the driver's speeding.
9.3.5. Achieving changes in attitudes and beliefs
In conclusion, it must be stressed that changing attitudes is a slow and difficult business. The
goal in any such programme is to reach a point where the control of compliant behaviour
shifts from external to internal factors, from externally-imposed rewards and sanctions to
intrinsic motivation, where the individual simply prefers to comply.
The route from external to internal control passes through two intermediate stages. The first
of these is guilt driven: the person obeys the dictates of conscience because he or she seeks
to avoid guilt (as opposed to wanting to follow the rules). The next phase is one of
identification. Here, the person identifies with the outcome of the compliant behaviour. He or
she may not like what this entails, but enjoys the "feel good" factor when compliant
performance has been achieved (i.e., we may not like the idea of answering a heap of
33
overdue mail, but are pleased with the results). Only at the final point of intrinsic motivation is
there no internal conflict.
Studies of addiction suggest that there are five stages in breaking a bad habit. The first stage
is pre-contemplative, the person has not even considered breaking the habit. The second is
contemplative, the person begins to feel that it might be a good idea to become free of the
habit but has made no firm decision to change. The third stage is making the decision, here
the person truly resolves to give up the habit. The fourth stage is actually stopping, and the
final stage has to do with procedures designed to maintain the non-addictive state.
Notice that actual behavioural changes do not occur until quite late on in the process. Many
techniques seeking to change behaviour might appear to have disappointing results in
objective terms, but they may have achieved significant subjective progress in prompting the
crucial decision to change.. Do not underestimate the importance of moving through these
preliminary stages before you can expect to see real results. Remember also that people are
not always able or willing to tell you where they currently stand along this scale. In short:
Keep trying, but don't expect overnight miracles.
9.4. Developing intrinsic motivation
Two psychologists, Edward Deci and Richard Ryan (1985), working at the University of
Rochester, have been researching into the bases of intrinsic motivation for many years. Their
findings, based upon work with both children and adults, are of considerable relevance to the
achievement of safe and efficient working.
9.4.1. Competence and autonomy
The satisfaction of two needs, in particular, is important for the development of intrinsic
motivation:
• The need to feel competent. The more an activity helps us to feel

competent the more we are internally motivated to do that activity.
• The need to feel autonomous. The more an activity helps us to feel that
we are able to exercise some degree of choice, or personal control over
our behaviour, the more we are intrinsically motivated to carry out that
activity.
If our work offers little opportunity to satisfy these basic needs, because we feel almost
wholly driven by external rather than internal motivators, we can become either passive,
exhibiting blind obedience no matter how locally inappropriate compliance to the rules may
be, or aggressive, looking for every opportunity "to screw the system".
Managers can help workers satisfy the competence and autonomy needs in two main ways.
First, by giving them encouraging feedback about their competence. Second, by providing
the workforce with challenges at just the right level so that they can experience autonomy in
overcoming them.
9.4.2. How events are perceived
One of the most important influences upon the development of intrinsic motivation is the way
we perceive the significance of the things that happen to us. For example, if we go for a job
interview and are successful, we can perceive this event in one of three ways.
34
• We were the best person for the job. If we believe this, then we feel both
competent and in control.
• We were just lucky. Believing this does not make us feel either
competent or in control.
• We got the job because we were seen as the safe candidate who would
not rock the boat. This view would also not make us feel particularly
good about ourselves.
The same events can be seen by people in three different ways:
• As informational, providing positive feedback on competence and making

us feel more self-directed.
• As controlling, providing clear evidence that we are being controlled from
outside.
• As de-motivating, providing evidence of incompetence or helplessness.
Feedback is more likely to be seen as informational if it emphasises the good points of our
job performance. Feedback will be seen as controlling if it is evaluative or if it stresses what
we should have done. Negative feedback, suggesting incompetence, is likely to be
experienced as de-motivating.
9.4.3. The effect of extrinsic rewards on intrinsic motivation
There is now a good deal of evidence to show that external rewards will encourage someone
to act in a particular way, but they are also likely to discourage doing the activity for its own
sake. For example:
• Paying 4-5 year olds to do art tasks decreased their desire to do them as
later measured in a free choice situation.
• Rewarding adolescents for puzzle solving with play on pinball machines
decreased their subsequent desire to play pinball.
• A group of journalists were paid for each headline over a short period of
time. Later, they showed little interest in writing them spontaneously.
Only journalists not so rewarded continued to write headlines regularly.
9.4.4. The effect of external controls on intrinsic motivation
Further studies showed that external controls, such as surveillance, the imposition of
deadlines, evaluation, goal-setting and enforced competition, have adverse effects upon the
intrinsically motivated. They may well prod people into activity and, on some occasions, elicit
good performance, but there is little inclination to engage in these tasks once the sanctions
have been removed. The evidence strongly suggests that these controls diminish intrinsic
motivation. Certainly, they enhance neither feelings of competence nor of self-directedness.
9.4.5. Promoting intrinsic motivation
The following measures have been found to be effective in promoting both intrinsic motivation
and self-control.
• Provide choices at the right level. That is, ones that are realistic in that
they do not provoke anxiety, nor cause boredom.
• Allow people to set their own goals. Setting one's own objectives and
fulfilling them is a great boost to morale. Even if -- of necessity -- the
goals must be set externally, then provide people with a choice of the
means by which to attain them.
35
• Provide positive informational feedback. This is one of the most efficient

and effective ways of enhancing intrinsic motivation. The more detailed
the feedback, the more useful it is.
• Provide constructive feedback. If it is necessary to tell someone how their

work could be improved, do so in a way that is seen as positive and
helpful by the recipient. Such guidance is given even greater weight if it
is preceded by positive feedback, highlighting the good points of an
individual's performance.
• Acknowledge the conflict between rules and local judgements. Make it

clear to workers that the organisation values their intelligence and does
not expect slavish adherence to the rules at all times. Make it evident
that managers share the individual's concerns about his personal safety,
and that the rules are not there simply to protect the organisation.
It hardly needs saying that in order for these measures to succeed, managers and
supervisors must be respected by the workforce. That means being visible in the workplace
and understanding the practical requirements of the task. Many of the problems described in
preceding chapters arise because managers' diaries often leave little or no time for site visits.
As a result, they grow increasingly remote from the difficulties and dangers of the workplace,
and see 'sharp enders' as people who must be controlled rather than as co-workers who want
to do a good job and whose views about how the work should be done safely are worth
hearing and acting upon.
9.4.6. Group discussion leading to intrinsic motivation
Alex Bavelas ( a student of Kurt Lewin) demonstrated the value of worker goal-setting in a
factory-based study, using group discussions (see Brown, 1954). The average rate of
production had been 60 units per hour, and the workers were asked to discuss the problems
of production among themselves and decide on a future production target. They suggested
(during the course of group discussions) a target of 84 units per hour to be attained within
five days. Although the previous ceiling had never exceeded 75 units, the proposed goal was
achieved and stabilised at 87 units per hour.
In control experiments, it was found that asking, telling, ordering or lecturing groups of
workers in order to get them to produce more had no results -- it was only when a group
decision had been arrived at that an increase in production was achieved and sustained.
The following comments of the social psychologist, J.A.C.Brown (1954), serve both as a
useful summary of the Bavelas study and as a fitting endpiece to this entire section on
intrinsic motivation:
People do not like to be ordered about like automatons; they like

to participate in a common task. They like to work for 'us' rather
than 'them'. Above all, goals set by someone else have little
emotional appeal for the group, but, when the goal has been set
by the group itself, it becomes a point of honour to see that it is
fulfilled. Mutual discussion and common agreement lead to the
group identifying the goals decided on with its own, and its total
energies are canalised into achieving that end.
36
10. Summary and conclusions
1. Violations play a major role in accident causation. Their principal effect is to render
subsequent errors more dangerous. This can be summarised as follows: violations +
errors = injury, death and damage.
2. Errors and violations have different mental origins, occur at different levels of the
organisation, require different counter-measures and have different consequences.
3. Everyone in an organisation, from the board room to the sharp end, bears some
responsibility for the commission of violations. It also follows that everyone in the company
has a part to play in minimising their occurrence.
4. Violations, like errors, can be categorised by their relationship to Rasmussen's

performance levels: skill-based, rule-based and knowledge-based performance.
5. Four categories of violations can be distinguished. Routine and optimising violations at the
skill-based level, situational violations at the rule-based level, and exceptional violations at
the knowledge-based level. The latter often involve the transgression of general survival
rules rather than procedures (e.g, jumping down to help a friend overcome by hydrogen
sulphide fumes).
6. Procedures are continually being amended to prohibit actions implicated in previous

accidents. Over time, these procedural changes become increasingly restrictive. Yet the
actions necessary to get the job done remain much the same. The scope of permitted
actions shrinks to such an extent that procedures are either violated routinely (at the skill-
based level), or (at the rule-based level) simply to get the job done.
7. The theory of behavioural economics offers a useful framework for considering the costs
and benefits of violating. At the skill-based and rule-based level, the benefits clearly
outweigh the costs. Moreover, violations bring instant satisfaction. Although the hazards
may be recognised, the risks are not. The costs are perceived as remote and improbable.
8. The goal of violation management should be to make the benefits of compliance exceed its
costs. Reducing routine violations means writing procedures that lead directly to a safer
and more efficient way of working. Reducing situational violations means designing and
equipping workplaces so that violating does not offer the only way of getting the job done.
9. On the roads, there is clear evidence that violators have more accidents than those who
are merely error-prone.
10. Violators tend to be young and male, having a high opinion of their skills and a strong
belief that these will keep them out of trouble. Women violate less than men, and
compliance in both sexes increases with age.
11. Persistent violators fail to perceive the risks because they are immunised by a variety of
beliefs and attitudes: "I can always drive myself out of trouble: "It couldn't happen to me."
"I'm no worse than anyone else, and in any case I'm a better driver than most."
12. Social controls, achieved through group techniques, are more effective in changing
attitudes and beliefs than are fear appeals.
13. Eliminating unwanted behaviour is a slow process that must be preceded by hidden
psychological changes. This is often denied by those involved.
14. Accident proneness tends to be a temporary phenomenon, associated with passing life
events.
37
15. Unstable extraverts are frequently involved in flying accidents, and probably in other kinds
as well.
16. Compliance is made up of two basic factors: unthinking rule-following and pragmatic
compliance. Whether or not people scoring highly on the latter violate depends upon
either the situation or the perceived legitimacy of the rule and/or the rule-maker.
17. People vary characteristically in the extent to which they believe they have direct control
over their actions.
18. Perceived risk does not appear to deter violations. Several shunting violations rated as
high risk were also rated as being frequently committed.
19. Four factors appeared to account for shunters' violations: competence (erroneous
violations), attitude (routine violations), work conditions (situational violations) and rare
circumstances (exceptional violations).
20. Managers are more likely to attribute violations to workers' laziness and their failure to
perceive the risks. Workers see violations as being caused by inapplicable procedures,
bad working conditions and production pressures from management. They also rate the
risks more highly than managers.
21. Procedural failures arise from conflicts between various organisational controls.
Administrative controls (procedures, regulations, rules) conflict with both personal and
group controls.
22. The same core organisational processes (design, construction, operations, maintenance,
communications, budgeting, scheduling, etc.) are the root causes of both errors and
violations.
23. Cultural factors, and especially the workforce's perception of the organisation's safety
culture, play a major part in shaping both compliant and deviant behaviours.
24. The most effective way of achieving desired workforce behaviour is through intrinsic
motivation. This requires that workers feel both competent and that they possess some
measure of choice or autonomy. Both extrinsic rewards and punishments diminish
intrinsic motivation.
25. Violation management, like error management, must go on at several levels at the
same time and all the time.
38
References
Battmann, W., and Klumb, P. (1993) Behavioural economics and compliance with safety
regulations. Safety Science, 16: 35-46.
Brehmer, B., Gregersen, N-P. and Moren, B. (1991) Group methods in safety work. Uppsala:
Institute of Psychology, Uppsala University.
Brown, J.A.C. (1954) The Social Psychology of Industry. Harmondsworth: Penguin Books.
Free, R. (1993) Doctoral dissertation. Department of Psychology, University of Manchester

(in preparation).
Green, R. (1992) Personal communication.
Maidment, D. (1993) Paper to Bad Homberg Safety Workshop.
Misumi, J. (1982) Action research on group decision making and organisational development.
In H. Hiebsch, H. Branstatter & H. Kelley (Eds). Social Psychology: Selected Revised Papers
from the XXIInd International Congress of Psychology. Berlin: VEB Deutscher Verlag der
Wissneschaften.
Parker, D., Manstead, A.S.R., Stradling, S.G., Reason, J.T. and Baxter, J.S. (1992) Errors
and violations on the road: A test of the Theory of Planned Behaviour. Journal of Applied
Psychology, 77, 94-101.
Parker, D. and Stradling, S.G. (1993) Unpublished report. Department of Psychology,

University of Manchester.
Parker, D., West, R., Stradling, S.G. and Manstead, A.S.R. (1993) Relationship between
behavioural traits and involvement in different types of accident. London: St George's
Hospital Medical School.
Reason, J.T. (1987) The Chernobyl errors. Bulletin of the British Psychological Society, 40:
201-206.
Reason, J.T. (1990) Human Error. New York: Cambridge University Press.
Reason, J.T., Manstead, A.S.R., Stradling, S.G., Parker, D. and Baxter, J.S. (1991) The
social and cognitive determinants of aberrant driving behaviour. Contractor Report CR253.
Transport and Road Research Laboratory, Crowthorne.
Rotter, J. B. (1966) Generalised expectancies for internal versus external locus of control of
reinforcement. Psychological Monographs, 80 (Whole No. 609).
Schulzinger, M.S. (1956) The Accident Syndrome: The Genesis of Accidental Injury.
Springfield, Illinois: Charles C. Thomas.
Tripod, vols I-III (1993) SIPM EPO/67. The Hague: Shell Internationale Petroleum
Maatschappij.
Uttal, B. (1983) The corporate culture vultures. Fortune, October 17.
Westrum, R. (1993) Cultures with requisite imagination. In: J. Wise, V. Hopkin & P. Stager
(Eds) Verification and Validation of Complex Systems: Human Factors Issues. NATO ASI
Series. Berlin: Springer-Verlag.
39

Bending The Rules

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Bending The Rules

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BENDING THE RULES

THE VARIETIES, ORIGINS AND

The aim of this paper is to present a state-of-the-art report on violations.

• What forms do violations take?

• the nature of the workplace,

If there is a single message to be communicated here, it is that everyone in an organisation,

2. Introducing violations and procedures

2.1. Errors and violations

Table 1. Summarising the main differences between errors and violations.

They are unintended. Violations usually involve deliberate deviations

• Together, errors and violations comprise the broad category of unsafe

• Errors and violations have several causal factors in common. This is

• Accidents are frequently associated with particular combinations of

2.2. Safe operating procedures

• "Hard" defences provided by fail-safe designs, engineered safety features

• "Soft" defences provided by procedures, rules, regulations, specific safety

Actions sometimes necessary

Rasmussen's performance levels -- skill-based, rule-based and knowledge-based -- have

• At the skill-based level, we carry out routine, highly-practised tasks in a

• We switch to the rule-based level when we notice a need to modify our

• The knowledge-based level is something we come to very reluctantly.

A convenient way of representing the characteristics of the three performance levels is as

Figure 2. Locating the performance levels in the activity space.

Three further points need to made about the activity space.

• As situations become more problematic (from top to bottom of the

Performance levels Error types Violation types

Skill-based (SB) Slips and lapses Routine violations

4.1. Skill-based violations

4.2. Rule-based violations

4.3. Knowledge-based violations

4.4. Transitions from KB to RB to SB

5. The behavioural economics of violating

• People strive to optimise their behavioural efficiency within the limits

• People invest limited resources (i.e., learning a skill) in the hope of

• All human actions are constrained, either by internal factors (physical,

Perceived costs of violating

Figure 3. Expressing behavioural economics in a graphical form. The circles

Perceived costs of violating

Perceived costs of compliance

Figure 5 Accentuating the positive.

6. Personal factors influencing the perception of costs and benefits

6.1. Common traffic violations

• Changing lanes without indicating (80%)

6.2. Age and gender

Violating drivers are:

6.3. Violations and road accidents

High accident respondents: Violation and error factor scores

6.4. Why do people violate on the roads?

The research on driving violations suggests that non-compliance is directly related to a

• Illusion of control: Violators overestimate the extent to which they can

• Illusion of invulnerability: Violators underestimate the chances that their

• Illusion of superiority: This comes in two forms. First, violators believe

Other important factors include:

• Aggression and other macho tendencies: Driving a vehicle provides two

consensus". High violators overestimate the proportion of other drivers

6.5. Personality factors

6.5.1. Accident proneness

As an explanation of repeated accidents in certain people, accident proneness refers to a set

In the course of a lifetime almost any normal individual under

If we were to pinpoint the main groups of "accident-makers" they

6.5.2. Unstable extraverts

Figure 7. The trait characteristics of stability-instability and extraversion-introversion. The top

Factor 1: Unthinking compliance