“Practical Drift”: Why people don’t always follow procedure and can Relationship Based Safety help?

RBSEach year many are injured or killed in incidents where following a procedure or using available safety equipment would have saved his or her life.  Both managers and safety professionals have asked, “Why do people take short cuts and put themselves at risk?”  This article will explore this question from a variety of perspectives ranging from the traditional to the more recent thinking related to complexity and relationship-based safety.

A vigorous discussion on Linked-in (Nov 2013) asking why people take short cuts attracted responses from 66 safety and health professionals from several countries. If you are a member of Linked-in you may view the discussion at this link. By way of conducting an informal study, I analyzed the comments and attempted to put them into categories to see if we might get a glimpse into the underlying assumptions that guide EHS professionals in understanding and addressing why people take risks that appear to be avoidable. This informal study shows that the perceptions could fall into four broad categories:

  1. Human nature (26 responses / 46%),
  2. Leadership & culture (10 responses / 17.5%),
  3. Production/financial pressures (11 / 19% responses),
  4. Operational/Management systems (10/ 17.5% responses).

Defining the Problem

Rosa - Figure 1Human nature includes ways of thinking, feeling and acting that humans tend to have universally, which can be regarded as both a source of both good and destructive tendencies.  Ascertaining the characteristics of human nature and what causes them are some of the oldest questions in human civilization.  This provides a hint as to the enormous complexity of defining the problem. Almost half (46 percent) of the explanations of why people take short cuts fell into this category.  Figure 1 is a summary of the perceptions on how human nature plays a part in an individual’s decision to take short cuts and risks.

Poor leadership and culture (figure 2) and production /financial pressures (figure 3) had ten and 11 responses respectively.  Arguably you could say that these perceptions are also related to human nature, however, we separate them because they appear to not place sole responsibility on the person performing the work.

Management systems (figure 4), which include rewards and consequences seems to weigh in fairly equally with production pressures and culture/leadership issues.

This analysis is not scientific but it provides a snapshot of a mindset in the safety and health profession on this very important issue.  It is encouraging that 57% of the respondents articulated multiple influencing factors. However, the indication that a negative assumption of human nature is frequently used to explain why people take short cuts is cause for concern. Are these assumptions correct?  Unless we are making decisions on how to address human performance based on facts, we are likely to take the wrong or insufficient actions.  The way we define the problem informs our strategies to correct it.

A New Perspective

Prominent researchers have brought into question the belief that human error is at the root of most accidents (Reason 1988, Hollnagel & Leveson 2006, Dekker 2006). The focus has turned from focusing on the individual to examining the influence of social relationships and operational systems. Our previous articles have shown how research points to relationships and social interaction as much stronger influences on how people choose to act than previously thought.

In this article we want to examine how beliefs and assumptions about human error as the most frequent cause of accidents might be wrong. These beliefs seem to stem from Heinrich’s triangle theory, which made the elimination of unsafe acts a primary objective. His theory made a lot of sense and was supported by many respected safety professionals (Bird 1969, Heinrich, Petersen & Roos 1980). Now this assumption is being questioned by recent research indicating that Heinrich’s research was flawed (Manuele 2011).

Not only has Manuele’s research uncovered defects in Heinrich’s original statistics, other research shows that, “human variability is what preserves imperfect systems in an uncertain and dynamic world,”  (Reason, 1988: 239). According to Reason, mangers attribute unreliability to unwanted variability. They believe that increasing consistency in behavior will increase system performance. This is why standard operating procedures, and automation are so prevalent.  James Reason provides many examples of famous events where human variability, just in time actions and adjustments, is what saved the day, not following procedure. He suggests that attempting to constrain human variability by prescribing a limited set of “safe behaviors” undermines the most valuable assets we have.

We do know that many an individual has been hurt by not following a basic safety procedure. So we have to deal with a reality where the solution is not black and white. While efforts to control accidents through policy, procedure and behavior interventions have proven insufficient, fatalities and disasters such as the BP Oil spill are not acceptable in companies with values to protect people and environment. So, how can we define and address the problem?

Practical Drift

Scott Snook’s (2000) “practical drift” theory provides direction for actions that could address the unpredictable nature of organizational behavior that produces disasters such as the accidental shoot down of the Black Hawk helicopters in Iraq.

He defines practical drift as “the slow uncoupling of practice from procedure” (p. 24).  He concludes that the typical response of tightening procedures and increasing penalties for failure to comply would inevitably lead to the same pathology because in time, the new procedures would also be ignored. Instead, he urges professionals and managers to realize that the important question is not how to fix pilot error, crew inaction or even practical drift. The more fundamental question is, what can be done given this reality of human behavior? How can practical drift be addressed if not with increased and tighter rules?

A beginning would be to accept that drift will occur, that it is a positive aspect of human nature and more rules are not the answer. It would be beneficial to explore how people come to believe that not following the procedure makes more sense, and engage people in an inquiry that could lead to a more profound sense of mindfulness in their work.  By increasing safety awareness through conversation and dialogue held with respected individuals we might prevent future tragedies more effectively than by increasing rules and procedures.

Given the level of uncertainty and a changing environment, drift is the only certainty. Engaging workers in identifying it and knowing when to bring it up for discussion is a challenge.  Getting buy-in and consistency will require routines and structures that are imbedded into the work. Workers will have to see it as beneficial to getting their work done right and efficiently.

In this regard the Relational coordination (RC) dimensions of effective communication can be quite useful. Its seven dimensions evaluate the health of the working relationships (trust and communication levels) to accomplish specific work processes.  In this case, the dimensions of frequency, accuracy, timeliness, problem solving, shared goals, shared knowledge and mutual respect would be measured in relation to communications about procedural changes (Carrillo 2011, 2012). For more detail see our blog explaining the RC theory and dimensions.

Relationship Based Safety (RBS)

RBS differs from behavior-based safety because it changes the focus from changing individual behavior to building collaborative relationships. We are being asked to consider moving towards approaches that support relationship building as a way to influence behavior, to lessen dependence on the types of controls we’ve been discussing, and broaden our understanding of how to work with human nature.  There are basic safety management systems that need to be in place. It is the role of the safety professional to evaluate those systems and advise.  However, the evidence indicates that we need to recognize that the quality of relationships in the workplace plays an equally important role.

It isn’t easy to champion investments for relationship skill building. We live in a time that puts a premium on the measurement of outcomes, on the ability to predict them, and on the need to be absolutely clear about what we want to accomplish. To aspire for less is to court the loss of professional credibility.  That is why we need to continue to search for reliable ways to measure relationship effectiveness. The Relational Coordination survey is one such instrument.

From a social perspective it is understandable why tight controls, accountability, and standards should have such power. Especially when the public is involved, the response is to tighten up, to mandate, to measure, and to produce action plans. The manager’s ability to exercise professional discretion is likely to be constrained when the public has lost confidence in management’s ability to control the risks.

This insistence on efficiency and control are dominant values today. Under these circumstances the aim of leadership development is typically in the arena of finance, strategy, and planning.  People are considered capital or expense. There is little provided in the area of relationship building, living with ambiguity, responsiveness to the unexpected and engagement of the imagination.

Regulators try to control drift through regulations and enforcement. It appears that human behavior is not responsive to that approach, since (especially when you factor in unpredictable social interactions) it is impossible to completely control the effect of messages and the quality of information sharing.  It is difficult to go against this grain.  There is very little room for exploration and learning from small mistakes. Leaders are constantly measured by dashboards, 360 evaluations and taught a series of “leadership competencies” that promote the fallacy that there is one correct answer.

In leadership, judgment replaces rules.  What constitutes the right qualitative relationships for any particular work is unique to that work.  Who should be at a meeting or huddle? It isn’t just about titles. Who brings a necessary perspective? One person may be known as pessimistic and must be balanced. Another may have the trust and confidence of the people needed for collaboration. Part of leading is knowing who to bring into the conversation that will surface the hidden issues.

To the extent that a leader can make it okay to learn from mistakes, people will talk about drift from procedure and learn from it. There is no way to manage in this way sitting behind a desk or through a computer. Managers must get comfortable with social interaction.

It might be hard to accept but workers and managers are always making up their world as they go, and fitting their actions under the umbrella of the way they see the world or the truth in that moment. Rules and procedures are an attempt to hold the world still and create a uniform decision making model. It works for a while, until the human mind shifts and creates a new understanding of what’s going on. Safety management is not exempt from that dynamic no matter how important the goal of eliminating harm and failure may be.


  • Bird, F. E. and G. L. Germain. (1969) Practical loss control Leadership.
  • BP. (2010, Sept. 8). Deepwater Horizon accident investigation report. Houston, TX: Author. Retrieved Nov 12, 2013, from http://www.bp.com/content/dam/bp/pdf/gulfofmexico/Deepwater_Horizon_Accident_Investigation_Report.pdf
  • Carrillo, Rosa A. (May 2010). Positive Safety Culture: How to create, lead and maintain, Professional Safety, 47-54.
  • Dekker, S. (2006). Resilience engineering: Chronicling the emergence of confused consensus. In E. Hollnagel, D. Woods & N. Leveson (Eds.), Resilience engineering: Concepts and precepts (pp. 77-92). London, U.K.: Ashgate Publishing.
  • Eisner, Elliot W. ( 2002) The Arts and Creation of Mind. Integrated Publishing Solutions: VA.
  • Goodman, N. (1978).  Ways of Worldmaking. Hackett Publishing: Indiana
  • Heinrich, H.W., Petersen, D. & Roos, N. (1980)  Industrial accident prevention. New York: McGraw-Hill.
  • Hollnagel, E., Woods, D.D. & Levenson, N.G. (Eds.). (2006). Resilience engineering: concepts and precepts. London, U.K.: Ashgate Publishing.
  • EHS Professionals Linked-in Group comments viewed 11/15/2013 https://www.linkedin.com/groups/EHS-Professionals-46570/about
  • Manuele, F. A. (2011 Oct).  Reviewing Heinrich: Dislodging two myths from the practice of safety. Professional Safety. 52-61
  • Snook, S.A. (2000). Friendly fire. Princeton, NJ: Princeton University Press.
  • Reason, J.T. (1988). The Human Contribution: Unsafe Acts, Accidents and Heroic Recoveries. Ashgate Publishing: VT.
Rosa Carrillo

Written by Rosa Carrillo

Rosa Carrillo, President of Carrillo & Associates, is a thought leader in transformational leadership for environment, safety and health. She brings 20 years of industry experience with all levels of the organization. Her results and many publications create instant credibility with leadership and the workforce. She is fluent in English and Spanish and is at ease working across many cultures. For more information, please visit her website: http://carrilloconsultants.com

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