Human error and the techniques can be used to help counteract errors. But there are two reasons why people don’t follow rules – the first is because of errors (Why do people make errors?), and the second is when people choose not to follow the rules. These are known in the human factors discipline as violations. Unlike errors, which are unintentional, violations are conscious decisions to knowingly break a rule. But there are a range of reasons why someone might do this, and not all of them are really bad!
One example is a ‘system-induced violation’ – this is when someone is forced to break a rule in order to get the task done. It might be because something has broken, or because the situation that occurs was never imagined by the people who wrote the procedures, or because two procedures conflict with each other and it is impossible to follow both. An example of a system-induced violation from road driving is breaking a red light because the traffic light has got stuck on red. You might sit there for a while waiting for it to change, but eventually you realise that you are going to have to break the light if you want to get where you are going.
Sticking with the traffic lights, another type of violation is the ‘routine violation’. This is where breaking the rule has become common practice and cyclists passing red lights are a good example of this. They know that technically they should stop, but they feel safer passing the light at red to keep away from the traffic, and over time it has become a common practice which in turn makes it more acceptable for more people to do it. Then there are situational violations – times when it is possible and usual to follow the rule, but in this case there are other things going on that mean the person judges the rule to be less important than usual. For example, if you break a red light to move out of the way of an ambulance.
All of these types of violations create ‘at-risk’ conditions. The rules usually exist for a reason and working outside them creates new risks. In many cases, the individual understands the risks and makes a judgement that the benefit of breaking the rule is bigger than the risk. But sometimes these judgements are made without a full appreciation of why the rule exists and what risks they are really running.
A final type of violation is the ‘reckless violation’. These are occasions when someone breaks a rule with the full understanding of the risk involved and for no better reason than it happened to suit them to do it. Maybe running a red light to get home slightly quicker. While all rule breaking in a safety critical industry like rail should be avoided, reckless violations are completely unacceptable.
When incidents occur where rules have been consciously broken, it’s important to understand the reasons why because that can help us determine the most appropriate response. For system-induced violations, it is probably most appropriate to re-visit the rule and make it work for that type of situation. For routine and situational violations, it might be necessary to re-brief the reasons why the rule exists and why it is important to obey it. And, as nobody wants to work with reckless colleagues, disciplinary action may be appropriate for reckless violations. The objective of all this is to make the railway as safe as possible and that means everyone has to understand their role and contribution to safety.
