EP Hearts and Minds:

Managing Rule Breaking

Hearts
AND
Minds

The Hearts and Minds logo is a Trademark of Shell and

can only be used with written permission of SIEP, EP-
HSE. Documents with the Trademark have been
checked for their correctness and effectiveness,

by Gerard van der Graaf and Charles
Malone, EP-HSE and Patrick Hudson and
Suzanne Croes, Leiden University
Gerard van der Graaf, Charles Malone and Patrick Hudson: For CV details see
September/October EPNL, page 57.
Suzanne Croes, a psychologist, has been working
on the Hearts and Minds research project
through Leiden University under supervision of
Patrick Hudson. She has been involved in both
Academic research and field trials (Oman,
Malaysia, Brunei, Egypt). Her main project was
“Improving Supervision”. Since April 2002 she left
the project to work as a QA HSE Engineer for an International Dredging company.

Why focus on Rule Breaking?

Analyses of major accidents in Shell have found that rule breaking and violations at both the level of the individual and of the organisation form one

of the most common causes of accidents. The Hearts and Minds brochure - Managing Rule Breaking - aims to get people to understand why rules are

broken in their area of work and to develop action plans to prevent rule breaking in order to create and sustain a compliance culture.

Why is rule breaking dangerous? — Failure to follow a
procedure, usually done for what feels like a good reason,
is not necessarily disastrous on its own. Multiple failures
are required for an accident to happen. The dangerous ele-
ment in such cases is breaking a rule, violating, without
informing others, and assuming other barriers will be kept
in place. Without communication, someone else may
remove yet another barrier. In combination with a simple
slip or lapse or technical failure, this opens the path to an
undesirable outcome (Figure 1).
Will writing procedures solve the problem? — It is not
possible to introduce a procedure for every situation, but
writing or changing procedures is a natural solution to prob-
lems, especially after an incident. This often leads to com-
plicated procedures and rules that are increasingly hard to
follow, or seen as irrelevant. Such rules should be regularly
challenged and open to constructive suggestions about how
to do things ‘better’. Without challenge people accept rule
breaking, which undermines respect for those rules that
should never be broken.

Can all procedures be challenged? — There are a small

number of rules that are the result of bitter experience.
Examples of such rules are the wearing of seat belts when
Barriers World
driving and double wrapping slings around casing during
Hazard/ or Controls
Risk offshore lifting operations. These rules form a no-go area
Work & and must be complied with as a condition of employment.
Organisation
Debate on such rules has to concentrate on how to ensure
compliance, not on whether they are appropriate.

Undesirable
outcome
Figure 1: Multiple failures The Brochure - Managing Rule Breaking — The
and their linkage to the Hearts and Minds programme is supported by a range of
release of a hazard. brochures to help people to improve. [Ref. 1]. The
Managing Rule Breaking brochure concentrates on a work-

56 Restricted to Shell personnel only - Exploration and Production Newsletter - November/December 2002 - EP 2002-7012
 H S E
Type of Violation Main causes Main solutions

Unintentional Poor writing Rewrite (use native languages and improve logic)
Understanding Complexity Reduce cross-references
Failure to understand users Assess understanding in staff & designers

Unintentional Poor training Test active knowledge of rules and procedures

Awareness Lack of availability on site Make easily accessible

Figure 2: Routine Unnecessary rules Scrap rules

Poor attitudes to compliance Improve attitudes
Completing the Weak supervision Force compliance

Procedures and Practices Situational Lack of resources Provide resources as required

Questionnaire. Failure to understand working conditions Apply Variance Procedures
Make realistic procedures with those involved

Optimising Personal convenience Make rules easier to follow

Opportunities Introduce rewritten rules
Improve competencies

Exceptional Unexpected situations – no obvious rules Train for the unexpected

Pressure to solve problems Develop situation awareness skills

shop process to help people in a particular work area to Figure 3: Violation types.
understand why rules are broken in that area. Once this
understanding is developed the workshop has tools to
enable the people in that work area to identify solutions
that will result in compliance.
Hearts
AND
Minds

procedure ?
Do we need this
How do you go about using the Brochure? — Once Procedure
Visitor plant access rules
sources
by procedure Falling objects, ignition
Hazards managed
problems with following rules have been identified, this
NO (Arguments)
YES (Arguments)
brochure can be used to drive the improvement process. Argument
This is an
Also an argument
This is an argument
Problems may be discovered as a result of specific inci- argument
Also an
argument
Argument Argument

dents, from audits and from observations. The workshop

process described in the brochure stimulates an open and
Possible solutions
ss compliance
honest discussion. The process can be run in a single ses- 13 – Remove, rewrite, discu
competence requirements
15 – Redesign, change controlled?
19 – What hazards are
sion lasting 6-8 hours or can be split up in small working
Solutions chosen
sessions after the initial introduction. These small work- nt of own staff from other
Rewrite rule: take accou
appr oved comp etences
ing sessions may take 30-60 minutes in, for example, reg- plant s with

ular morning or HSE team meetings. Ensuring compliance Figure 4:

Example of challenge
The first step of the workshop is to establish what drives process.
the participants to break the rules through completion of
a questionnaire (Figure 2). A further analysis provides an
indication of the type of violation that is most prevalent in
the participants work area.

There are six types of violations and these are outlined in * An example of a “forcing function” is where you cannot
Figure 3 . start a car without the seatbelt being engaged.

The participants then identify some examples of rules that

are broken in their work area that typify the violation type
identified by the questionnaire. One of these rules is taken
forward through a challenge process to establish solutions
that can improve compliance of the rule (Figure 4). The
brochure provides hints and solutions to the six violation
types and also guidance on how to create compliance
through various routes e.g. rewards, group processes, forc-
ing functions* and accountability.
What do you do with the output from the workshop? —
Once the workshop process is complete each syndicate
team develops a personal action plan. This plan translates
the solutions developed in the workshop into actions that
can be implemented back at the workplace. If problems
with many other rules or procedures are identified, the final
part of the workshop process can be repeated in short ses-
sions during subsequent morning or HSE team meetings.

Restricted to Shell personnel only - Exploration and Production Newsletter - November/December 2002 - EP 2002-7012 57

How do you sustain the improvement process? —
The process in the brochure should not be seen as a one-
off event or initiative, which the people can walk away
from. If this is the case the process will “die” and so will
the development of a compliance culture. Instead the
brochure and process invites to be regularly be applied e.g.
every 6-12 months. If this is done it will become “alive” and
will enable a compliance culture to be developed.
Who is the brochure for? — The brochure is aimed at
all levels of an organisation and should include the work-
force, as well as managers and supervisors. During the
workshop groups should be organised in terms of common
trades or disciplines. As management is a source of rule-
breaking problems in its own right, managers can also
form separate groups.
What is the status to date? — Managing Rule Breaking
workshops have already been done in more than fifteen coun-
tries, creating further requests for the brochures, of which
nearly 10,000 have already been distributed. People find the
process easy and stimulating to apply and keep finding new
ways to use the brochure and the concepts it represents.
They have not only been done within EP all over the world,
but also in Shell Chemicals, Shell Aircraft and some down-
stream operations. The terms such as Sheep and Wolves,
and the different types of violations e.g. situational viola-
tions have become known well enough that people are
beginning to find it natural to talk about them.
How do I get a copy of the brochure? — SIEP-EP-HSE
has the brochures available on request and can provide ini-
tial advice and support to introduce the tools. The EP HSE
website [Ref. 3] has all the information that you need, as
well as facilitators’ notes.
58 Restricted to Shell personnel only - Exploration and Production Newsletter - November/December 2002 - EP 2002-7012
H S E
References
[1] van der Graaf, G.C., Malone. C., & Hudson, P.T.W. (2002)
“Hearts and Minds - The Road Map”. EPNL 2002-7010.
[2] van der Graaf, G.C., Malone. C., & Hudson, P.T.W. (2002)
“Hearts and Minds - Understanding Your Culture”. EPNL
2002-7010.
[3] EP-HSE Hearts and Mins Website:
http://sww.siep.shell.com/hse/handm/handm.htm
[4] van der Graaf, G.C., Kalff, J., & Hudson, P.T.W. (2000)
“Intrinsic motivation for HSE. Part 1: The Hearts and
Minds HSE research programme”. EPNL 2000-7004.
[5] van der Graaf, G.C., Kalff, J., & Hudson, P.T.W. (2000) “Moving
towards a ‘Generative’ safety culture. Part 2. The Hearts and
Minds HSE research programme”. EPNL 2000-7006.
Conclusion
In situations where effective ‘hardware’ barriers cannot be
established, guidelines, rules and procedures provide one of the
most effective ways of managing hazards. Failure to follow
established rules and procedures removes one or more of these
barriers. In combination with a single error or mechanical fail-
ure, violations can lead to disaster. Rule breaking therefore
forms a major threat to the integrity of the HSE management
system (HSE-MS). Analyses of major accidents have found that
rule breaking, violations at both the level of the individual and of
the organisation, forms one of the most common causes of acci-
dents.
The Managing Rule Breaking Brochure helps small groups to
identify the existence of problems relating to rule breaking and
find approaches to manage those problems. The brochure also
provides background information about six different types of
rule breaking and tools to help in creating compliance in indi-
viduals or groups at all levels of an organisation.