My notes and other stuff


Following Procedures Dilemma

Reading Nancy Leveson's Engineering a Safer World and I am once again reminded that Sidney Dekker is extremely quotable, here on the "Following Procedures Dilemma":

Dekker notes what he called the “Following Procedures Dilemma”. Operators must balance between adapting procedures in the face of unanticipated conditions versus sticking to procedures rigidly when cues suggest they should be adapted. If human controllers choose the former, that is, they adapt procedures when it appears the procedures are wrong, a loss may result when the human controller does not have complete knowledge of the circumstances or system state. In this case, the humans will be blamed for deviations and nonadherence to the procedures. On the other hand, if they stick to procedures (the control algorithm provided) rigidly when the procedures turn out to be wrong, they will be blamed for their inflexibility and the application of the rules in the wrong context. Hindsight bias is often involved in identifying what the operator should have known and done.

Insisting that operators always follow procedures does not guarantee safety although it does usually guarantee that there is someone to blame—either for following the procedures or for not following them—when things go wrong. Safety comes from controllers being skillful in judging when and how procedures apply. […O]rganizations need to monitor adherence to procedures not simply to enforce compliance but to understand how and why the gap between procedures and practice grows and to use that information to redesign both the system and the procedures.