Understanding Violations and Boundaries

Authors : Amalberti, R., Auroy, Y. & Aslanides, M.
The Canadian Healthcare Safety Symposium, Edmonton 2004

The notion of deliberate deviations from rules, standards, and recommendations is a central topic of safety analyses in industry. Deliberate deviations (called violations) are different from involuntary errors and are extremely numerous among front-line actors (the operators driving a process).Some dramatic violations have become celebrated cases. In 1987, the ferry, Herald of Free Enterprise, left Zeebrugge’s inner harbour with the back ramp partly open to save time (Reason, 1990). The boat took on water and was shipwrecked. In 1999 an accident occurred at a uranium-processing plant operated by JCO in Tokai-Mura, Japan. The accident was caused by workers’ unsafe actions. They were anxious to finish their job at the conversion building and decided to use the precipitation tank instead of a buffer column (a much smaller device) to increase their performance when purifying and homogenizing uranium. The concentration of product became critical and the system exploded, causing the most severe nuclear accident since Chernobyl (Furuta, 2000). In both cases, accident analysis showed that the workers’ deviations from normal operating procedures resulted from a long progressive drift in practice.Most violations fortunately result in much better outcomes. In aviation, an extensive study of crews’ errors (noted by trained observers sitting on the jump seat for some 3500 flight segments) showed that ‘intentional non compliance’ represented 45% of all ‘errors’, but only 6% of these led to an undesired aircraft state (Helmreich, 2001). (...)

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