Actions That Support A Culture of Procedural Compliance in High Reliability Organizations

I count myself very blessed to have spent most of my adult life operating US Navy Submarines. Procedural compliance was expected from day one onboard…our lives depended on it. A submarine is an effective warfighting machine because of the people that operate it. When the general alarm sounds or an order is issued by the Officer of Deck (OOD) an entire team of individuals performing small but vital actions throughout the ship must respond at the right time with the right action for the ship to survive a casualty, defend itself in battle, or return home to its berth.

Why is procedural compliance important?

In any situation where people operate complex and high consequence technology procedures provide consistency and predictability in operations. We learn procedures and everyone on our team should be able to predict the outcomes and recognize when something isn’t right. Procedures coordinate all of the individual actions into a single coherent and effect response by a ship, a refinery, a power plant or even the physical plant that supports a hospital. They level the playing field between experienced and new operators helping to reduce the cyclic nature of our respective businesses.

A story in Dr. Atul Gawande’s (2009) book The Checklist Manifesto: How to get things done right highlights for me the problem of increasing complexity and the need for simple tools to help prevent errors:

October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S. Army Air Corps held a flight competition for airplane manufacturers vying to build the military’s next-generation long-range bomber. Boeing Corporation’s gleaming aluminum-alloy Model 299 had trounced the designs of Martin and Douglas. Boeing’s plane could carry five times as many bombs as the army had requested; it could fly faster than previous bombers and almost twice as far. A Seattle newspaperman who had glimpsed the plane on a test flight over his city called it the “flying fortress,” and the name stuck. The flight “competition,” according to the military historian Phillip Meilinger, was regarded as a mere formality.

A small crowd of army brass and manufacturing executives watched as the Model 299 test plane taxied onto the runway. It was sleek and impressive, with a 103-foot wingspan and four engines jutting out from the wings, rather than the usual two. The plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill.

The investigation revealed that nothing mechanical had gone wrong. The crash had been due to “pilot error,” the report said. Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, each with its own oil-fuel mix, the retractable landing gear, the wing flaps, electric trim tabs that needed adjustment to maintain stability at different airspeeds, and constant-speed propellers whose pitch had to be regulated with hydraulic controls, among other features. While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.” The army air corps declared Douglas’s smaller design the winner. Boeing nearly went bankrupt.

The Army purchased a few aircraft from Boeing as test planes, and some insiders remained convinced that the aircraft was flyable. So, a group of test pilots got together and considered what to do. What they decided not to do was almost as interesting as what they actually did. They did not require Model 299 pilots to undergo longer training. It was hard to imagine having more experience and expertise than Major Hill. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But flying this new plane was too complicated to be left to the memory of any one person, however expert.

In our increasingly complex world, procedures can be simple checklists that act as cues or reminders to take the necessary steps to complete an operation safely. The fact is we are error prone. We are susceptible to memory lapses when in a hurry or stressed. Procedures are not a guarantee of success, but they at least give us fallible humans a fighting chance. 

Aside from expecting procedural compliance, it is the way nuclear submarines are engineered that makes procedural compliance easier. Very few machines that man has built are engineered closer to 100 percent than a nuclear-powered submarine. We have procedures that are proven to work, easy to follow (mostly), and readily available. NAVSEA (the Navy’s engineering organization) and their partners prepare detailed procedures for operations and casualties. Preparing procedures in this manner allows deliberate and thorough consideration by a number of people of all the factors involved. It also provides a large degree of standardization and provides a means to improve the procedures based on operating experience.

I recognize this level of engineering is exceptionally expensive in time and money, however the risks to personnel and the environment are exceptional too. This level of engineering is cheap insurance, buying down the risk of an outcome we cannot except.

As I said earlier, there are few machines that equal the level of engineering a nuclear power submarine receives. Fortunately, other industries that work with high energy or dangerous materials can take some simple and relatively low-cost steps to make procedural compliance easy for their operators:

1) Write procedures they will use – provide utility out of the box.

• Keep procedural steps simple, ideally one operator action for each step. Some of the procedures I review are in story form explaining why and how the step is performed. The procedures are rich in information (including pictures or diagrams) and pertinent safety warnings which are helpful and necessary, however this format is more likely to lead to confusion and possibly missing an action. A better format might consist of a two-column format with action steps on the left-hand side (first) with supporting principles/cautions/warnings/images on the right-hand side.
• Written to the experience level of the operator. Poorly written or confusing procedures introduce risks into operations when operators lack the experience to navigate them to the right answer for a given situation.
• Distill long procedures down to simple checklists. A 30-page instruction to conduct Lockout/tagout (LOTO) probably will not get opened. A laminated and verified up to date 1-page (front&back) checklist for major processes (hanging/modifying/removing) that are posted in the workspace will more likely be referenced by the operator. Better yet modify LOTO forms so they are the procedural checklist.
• Make procedures readily available and keep copies current with the latest revision. Many procedures live in file folders buried deep on share drives or in a dusty binder on a shelf several revisions out of date.

2) Teach your people why procedural compliance is important to safety, effective operations and most of all you. As leaders we owe our people an appreciation for the importance and danger in their work and an appreciation for how they will safely manage that energy to make a product or provide a service. Teach them not to violate procedures or go around them when they discover the procedure doesn’t work. They need to stop, speak up, and resolve the problem with the procedure. This takes self-discipline and commitment by leadership to resolve questions and problems in a timely manner. Additionally, ensure new hires are trained using the procedures.

3) Label your valves and switches. This does not appear to be very common in the commercial world. Labeling valves can be a heavy lift as some facilities have hundreds or even thousands of valves. The payoffs are many:

• More accurate LOTO isolations and many cases a lot less time is spent investigating and proving the isolations are adequate to protect the job site.
• Easier to write and read procedures. A procedural step can read, “Open FW-10” instead of “open the feedwater inlet isolation valve to the boiler feedwater pump”.
• Allows the facility to develop normal operating, startup and shutdown valve line-ups.

4) Verify valve and switch line ups. Once you have labeled your valves and switches, periodically (e.g., prior to restart after an outage) verify the position of these components. This will ensure equipment and systems are ready to support operations. Valve line ups also ensure critical safety equipment and safeguards are available to protect facilities, personnel, and the environment.

5) Update your drawings with valve and component labels and normal positions. Accurate and complete system drawings provide confidence when isolating portions of the system for maintenance, provides a better source document for troubleshooting, and gives the operator a picture of what right looks like making it easier for them to detect abnormalities.

6) Set an expectation that procedures are used and then inspect your expectations. Most organizations set standards, but do you go out into the facility or field and see what is actually happening. I agree we should trust the professionals working for us and this discussion is not about trust…it is about leadership…getting on the deckplate and experiencing how work is done. Look for roadblocks to using procedures – show interest – if you are interested, they will be interested. Most if not all of your people want to do the work right…it is up to you to show them what right looks like. Every management system ever invented by man is of limited value unless leadership engages with the people using it – are they using it, if not why? how do we make it better?

Operating modern production and power generating facilities properly requires a knowledge and understanding of the characteristics of many systems and components, and of their interactions. Reliance must ultimately be placed on the operator. Compliance with approved operating procedures by properly trained individuals is required. However, because not all situations can be foreseen during the complex operations, your people must understand when and which procedure to apply in a situation with an understanding of the desired outcome of that procedure. Blind procedural compliance will not produce success.