When undetected deviation becomes an incident

Dave Rebbitt
The phrase normalization of deviation was made famous by the investigation report from the space shuttle Challenger. This speaks to how deviation from requirements or safe practice became normal and accepted.

Very few organizations have systems in place to detect deviation from established processes in order to prevent ongoing normalization leading to an error that causes an incident. Most companies would point to annual or quarterly audits but these only confirm what most in the company already know. Some external audits review documents and procedures to ensure they are present but cannot really determine whether they are followed or effective.

An organization’s procedures and processes with respect to health and safety fall into two categories — program or system. A program is a set of processes and procedures that is created by the company and imposed upon the workforce. Deviation from process is seen as an error and the program is re-imposed through coaching, training, or even discipline.

A system is somewhat different. A system relies on continuous improvement for effectiveness. Deviations from processes lead to the examination of the process to determine if it is effective. Rather than assuming the deviation is wrong, a system recognizes deviation as natural and something that can lead to improvement or even innovation.

So, detecting deviations from established processes and procedures is important because they can lead to both improvement and error. Detecting these deviations is normally a result of an incident investigation instead of any effort to proactively discover them. In a large company or one with a contingency workforce, turnover can accelerate the normal deviation timeline. Instead of years for a deviation to grow and become normalized to the point where it can cause an incident, the process may take only months.

Deviations can be simple like skipping a step in a procedure because it is not well understood. In some cases it can mean not completing required paperwork since no one has ever asked to see it. In other cases “just this once” can become an accepted practice. Making do with equipment awaiting a minor repair may lead others to believe the equipment does not need repair at all.

Every company has systems or programs in place attempting to prevent errors. These errors can be all too obvious after an incident but are often a result of normalization, the growing deviation from what is required may appear normal and acceptable to those involved.

Detecting such deviations is not easy. This is not because anyone tries to hide them but because they must be specifically looked for. If a company audited a key safety process to determine if it was being accurately followed many would perhaps expect that it was followed 100 per cent of the time or very close to that. The reality is somewhat different. In my experience the average is about 75 per cent to 80 per cent. This means that the key process is not being fully followed 20 per cent to 25 per cent of the time. While this may be a bit shocking, it is the inevitable result of normalization of deviation.

Geographically diverse companies may see even more of a shift. Locations with different legislation or other quirks are much more likely to deviate from processes designed at the head office far away.

Some companies have systems that allow them to audit specific processes and these can be helpful in detecting variances. Most companies content themselves with a basic audit each year. In order to determine if processes really are effective the exercise would involve normal elements of an audit.

A review of the documentation required by the process should be conducted. The mere presence of the documents does not establish alignment, they must also be reviewed to ensure completeness and quality. The working process in use must be directly observed as documents can be completed without actually following the process. If appropriate, interviews may also be conducted to gauge how well those using the process understand it.

When deviations are found it is not a matter of enforcing compliance or retraining employees. Perhaps the most important thing is understanding why deviations developed. In systems thinking, a process that does not serve the needs of the operation will never be effective, or followed.

In detecting deviation some simple questions must be answered:

•What caused the deviation? It may not be entirely possible to determine where the deviation began as this is a normal process and the length of time it has normalized can be considerable. However, finding the cause will definitely help find the solution.

•Does the deviation create additional risk or hazard? Just because a policy or procedure is not being followed it is not the end of the world. You really need to ask if this is an issue or not. There is always more than one way to accomplish a task.

•Does the deviation improve the process? Have you gotten lucky and found innovation? This may be a cause for celebration and some recognition.

•Is the deviation widespread or localized? Often deviations are localized but may be indicators of widespread issues with a particular process. If there is a large deviation from the established process and procedure at one location, chances are it is not localized but that other locations are probably deviating in different ways.

•Should the process be changed? This really comes down to what the issue is. If people simply do not like the requirements then a redesign or review is wise. In most cases minor changes must be made; in others a major overhaul is required.

Reviewing a process or procedure can prompt involvement from employees in making changes that improve processes or procedure but still accomplish what they are required to do. This can be like finding gold as real opportunities to involve employees in process design are not all that common.

In some cases companies may have a specific or focussed audit for key processes to assist in identifying deviations. Much like quality control, we have to acknowledge that a system is only prefect at the moment it is launched. From there it begins to deviate as it interacts with the human element of the workforce and the dynamic workplace. Safety systems must be run in much the same way as quality control: where errors are actively sought out and output is consistently measured against a quality standard.

Process or procedure reviews need not be complicated and can be accomplished fairly quickly given the right guidance and resources.

If your company has a significant percentage of high risk incidents or events sharing the same process, chances are there is an issue you may not be seeing. So why not take out what you may consider a key process and see just how well it is followed? The result could be a surprise and lead to improved communication and processes.