Received: 24 March 2023 Revised: 20 June 2023 Accepted: 20 June 2023

DOI: 10.1002/prs.12505

ORIGINAL ARTICLE

Why the term “operational discipline” is not helpful, and better

options for instilling positive process safety culture

Jody E. Olsen

JE Olsen Consulting LLC, Anchorage,

Alaska, USA Abstract
Language matters for effective leadership and culture. And the language embedded in
Correspondence
Jody E. Olsen, JE Olsen Consulting LLC, the term “operational discipline” is not helpful. This term is inconsistent with decades of
Anchorage, AK 99509, USA.
learning on cause analysis, systems thinking, and human performance. Humans typically
Email: jodyo@jeolsenconsulting.com
do not fail because they are not disciplined enough. Failures occur for other reasons that
stem from the systems within which the humans are working. For many people, the
term “discipline” has a negative or punitive connotation. And the term “operational”
focuses the spotlight on operations. The two terms taken together may imply to some
people that willful operator deviations are the root cause of some incidents. Failures
typically involve a range of management processes and functional groups. Thorough fail-
ure analysis can identify systemic causes, and follow-up corrective actions may be tar-
geted at the upstream sources. Healthy culture requires a positive, inclusive, and curious
environment that seeks to continuously learn and improve without casting blame. Even
if the term “operational discipline” is not intended to place blame, the choice of words
defeats that aspiration. When seeking to improve process safety culture, choose lan-
guage that supports a positive learning environment of ownership and empowerment
by the workforce. And support those words through management actions.

KEYWORDS
conduct of operations; culture; human factors; human performance; operational discipline;
process safety; root cause analysis, RCA; systems thinking

1 | I N T RO DU CT I O N work settings, human error is rarely caused by lack of discipline. Fail-

The term “operational discipline” has been espoused as a means of
achieving process safety goals. However, this term, and what it stands
for, is inconsistent with decades of learning on root cause analysis
(RCA) systems thinking,1–3 human factors, and human performance. In
This article was originally presented at the American Institute of Chemical Engineers
2023 Spring Meeting and 19th Global Congress on Process Safety, Houston, TX, March
13–15, 2023.
ures occur for other reasons that are baked into the systems within
which humans are working.
Language matters for effective leadership. And leadership lan-
guage sets the tone in establishing culture. Operational discipline can
sound punitive and point blame at the operator or operations. When
incidents occur, deficiencies are generally found throughout a range
of work management processes and functional groups. And, impor-
tantly, the deficiencies span vertically through company management
as well as laterally through functional disciplines and process safety
management (PSM) practices.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes.
© 2023 The Author. Process Safety Progress published by Wiley Periodicals LLC on behalf of American Institute of Chemical Engineers.

70 wileyonlinelibrary.com/journal/prs Process Saf Prog. 2024;43:70–79.


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This article will define the problem, provide background, and offer
several stepping stones to support moving an organization toward a
more positive and effective safety culture. We look at tools from lean
manufacturing that have driven improvements in reliability. We look
at sectors outside of the processing industries—including the
U.S. Nuclear Navy and the airline industry— to find examples of where
high-reliability practices have been institutionalized. Although not all
processes are directly transferable, these successes offer opportuni-
ties to learn and implement better practices.
2 | T H E P R O B LE M
For many years, operational discipline (OD) has become a popular tag-
line for the culture that needs to be in place to ensure sound work
practices and safe operations. The term “operational discipline” was
coined in industry by the mid-2000s4 and adopted by the Center for
Chemical Process Safety (CCPS). The term was referenced in the
5
CCPS Guidelines for Risk Based Process Safety (RBPS) in conjunction
with the Conduct of Operations element. In Chapter 17 it says, “[Con-
duct of operations] is also sometimes called ‘operational discipline’…”
A CCPS book dedicated to that chapter was published in 2011.6 The
terms have been moderately redefined over the years but remain
close to the original descriptions.7 The current definition of opera-
tional discipline according to the CCPS website is “The performance
of all tasks correctly every time.”8 This definition is consistent with
prior OD mantras of “Everyone, Do It Right, Everytime.” 4
These words imply that, if only the personnel were doing the
work as the procedure and the process prescribed, incidents would
not occur. However, many times when we perform root cause failure
analyses for incidents in industries regulated under PSM, we find that
no quality procedure exists. The procedures may be nonexistent, out
of date, incomplete, unclear, hard to read or use,9 or contain errors or
have other flaws. And it is not unusual that the causal factors for the
incident may have stemmed from personnel attempting to comply
with a poorly crafted procedure. In addition to potential procedural
deficiencies, the circumstances at the time of the incident may have
prevented or disincentivized the operator from using the procedure.
If discipline were the problem, the RCA would find that
operator(s) made willful choices not to do something that they knew
they were supposed to do and were able to do. Consider a broken
New Year's resolution to stop eating candy or workout every day.
When we break our resolutions, we willfully deviate from what we
know we should do and what we— ourselves—want to do. We seem
to lack the discipline to keep our own resolutions. However, even in
this case, the truth may be that there are root causes that set us up
for failure. Perhaps, we have set unrealistic or unachievable resolu-
tions. Perhaps we set those goals without having the tools to form
new habits and to make positive changes.
When operators are found to have not conformed to procedures
or protocol that led to major incidents, the incident reviews will gener-
ally find reasons that contributed to the operator not using the proce-
dure or not being able to use the procedure. Beyond issues with
deficient procedures or processes, the operator may have been
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71
dealing with a flood of alarms, hazards may not have been identified,
communication processes may have failed, new electronic work man-
agement systems may not have been fully functional, and many other
reasons.
And what about the other people?
What about the engineers who signed off on incomplete techni-
cal reviews or poorly performed process safety reviews on changes
and projects? Did they do those things because they lacked engineer-
ing discipline or because the management systems allowed them to
fail? Were there sufficient checks and balances in the process? Did
the process require technical reviewers with defined skills, training,
and qualifications perform those reviews? Was the purpose for the
checks and balances understood and reinforced?
What about managerial discipline?
What about supervisors who signed off procedures during 3-year
reviews that do not reflect the way work is performed in the field?
Did the review process require operational and technical reviewers to
sign off in conjunction with the supervisor? Did the supervisor ensure
that all reviews occurred? Were onsite reviews conducted? Did the
supervisor have sufficient knowledge or resources on how to align
work activities with usable procedures? Did they understand human
performance models?
What about the managers accountable for effectiveness of the
PSM systems? Are they aware that the procedures are incomplete
and unusable? If not, why are they not aware? What steps have they
taken to correct those systemic deficiencies? Have they engaged
operating and technical staff in the process for improving those proce-
dures? Have they allocated budget and prioritized that work? Is a pri-
oritization system in place to address deficiencies that involve the
highest risk scenarios ahead of less critical work?
How were these operating procedures certified annually, as
required by OSHA PSM, as being “current and accurate”10 if the pro-
cedures are not aligned with the way “work is done” in the field?
Managers who preach the need for operational discipline believe
that it is possible to stamp out the normalization of deviation that is
preventing their company from achieving the stated goal of “Every-
one, Do It Right, Everytime.”4
Importantly, they seem to misunderstand the wider systemic
causes and fail to recognize the fallacy in the simplistic statements “Do
It Right, Everytime” or “perform tasks correctly every time.” What is
“right” or “correct” when the systems are strewn with defects and
when successful performance may require adaptation by humans?1,3,11–
13
The more productive stance is to acknowledge that defects exist
because systems are not perfect3 and that human error is normal.1,2,14
The goal should be to find and eliminate defects, to equip the humans
with tools that make mistakes less likely,9,13 and to reinforce systems so
they have more capacity, that is, resilience, to absorb errors.3,12,14
In a series of articles on Admiral Hyman Rickover's building of
the first—and potentially only— high-reliability organization, the U.S.
Nuclear Navy, Mark Paradies takes the unusual stance that normaliza-
tion of deviation is in fact everywhere!15,16 He is correct! It is embed-
ded in the human condition to not perfectly follow the rules,
instructions, advice, and guidance that we are given, not to mention
our own plans, such as those New Year's resolutions. To achieve
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72 OLSEN

incremental improvement in moving toward more perfect confor-

mance, we must understand the realities and the barriers to getting
there, and we should replace the “stick” with the “carrot.”

3 | W E H A V E A L O N G WA Y T O G O , … H O W
D O W E G E T T H E RE ?

Unless you are working within a handful of industries that instituted

high-reliability practices many years ago, such as the Nuclear Navy,
the civilian nuclear industry, NASA, the airlines, or perhaps the post
office, the concerns raised above may likely ring true for your organi-
zation. If your company has not had major or serious near-hit inci-
dents (recently), is it because these issues are not present in your
organization, or have you been lucky? Investigation after investigation
by the U.S. Chemical Safety and Hazard Investigation Board (CSB)
reveals management system failures that span a wide range of PSM
elements and process safety practices. So where would a company
start and how do we address a large number and broad range of sys-
temic deficiencies?
How can we replace the “stick” of operational discipline with a
more positive—and potentially more effective—“carrot?” How do
we move toward better practices that will engage the workforce to
migrate toward more excellence as Rickover strived for and
achieved in the Nuclear Navy? Interestingly, as described in the
Paradies article series, neither in the 3 overriding tenets that Rick- F I G U R E 1 Admiral Hyman G. Rickover, known as the “Father of
over espoused nor in the more detailed 18 building blocks refer- the Nuclear Navy,” directed the original development of the Nuclear
Navy and controlled its operation for three decades as director of
enced in Rickover's testimony do we see the term “operational
U.S. Naval Reactors.19 The rigorous standards that he required enabled
discipline.”16,17 Strict conformance with specific expectations was the high-reliability performance that the Nuclear Navy has achieved.
and is an essential part of the nuclear naval program. Those
requirements are prescribed in defined terms,17,18 not as a vague
reference. Non-conformance is enforceable by disqualification. So, what is to be done? … Can we even make a dent?
This means the standards were and are rigorously developed so I am not in favor of eating elephants, but as the saying goes, the
that conformance is achievable (a portrait of Admiral Rickover is only way to do it is to start … one bite at a time.
shown in Figure 1). One starting point, perhaps we replace the term “operational dis-
Outside of the military, industry faces several obstacles to cipline” with “operational excellence” in the lexicon.
achieving the high-reliability performance that Rickover put in
place. Those obstacles include the fact that he built those elements
into the organization from its inception. The extraordinarily high 4 | STEPPING STO N ES
level of technical training, qualification, and re-qualification
required by personnel from the top to the bottom of the organiza- Here are several key stepping stones to making improvements. They
tion is well beyond the requirements that exist in typical industrial all relate to operational excellence through better understanding of
settings. Extensive resources are dedicated to the entire program human performance models. Operational excellence could be sup-
including procedure development and improvement. Importantly, ported by work in the following areas:
the cost structure within the Nuclear Navy, which is driven by
safety imperatives, does not resemble the budget allocations in 1. Insist on full management accountability
other industries. Although the cost of incidents is understood to 2. Perform rigorous technical review and validation
be high, the day-to-day cost of doing business in a manner com- 3. Foster employee ownership by enabling the workforce (at all
mensurate with the Nuclear Navy is a barrier to industry. And the levels)
culture of organizations outside of the military is not likely to be 4. Develop usable procedures by integrating human factors learnings
conducive to the rigorous expectations placed on personnel at all 5. Prioritize like a demon (based on defined parameters)
levels, including the knowledge that termination is the result of 6. Conduct failure/cause analysis early and often
failure at any checkpoint along the way. 7. Reward proactive continuous improvement efforts.

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Each of these points could be an entire article. For the purposes of
this paper, I will touch on several tools or suggestions that may help in
taking initial steps toward improvements in each area. Note that these
seven areas are not intended to replace or supersede efforts associated
with all elements of PSM,10 RBPS,5 or internal company operational and
safety management programs. The intent in highlighting these seven is
to address several critical elements that may help in tackling wider sys-
tem deficiencies impacting procedural conformance and the ability to
optimize human performance. These seven items can also help redirect
the focus from discipline to ownership and empowerment.
4.1 | Insist on full management accountability
The need for accountability is driven home in Mark Paradies's article
series on Rickover. Rickover does not play with words regarding the
subtle distinctions between responsibility and accountability. In most
organizations, accountability is reserved for the top levels, with lower
levels having responsibility. In his Nuclear Navy, total responsibility
starts at the top with Rickover. And responsibility for safety and tech-
nical competence is then passed down through every level in the
chain of command.16,20
Again, how can we make a dent in industries that are a great dis-
tance from this model?
To be accountable (or responsible), the manager must be aware. If
the manager has no awareness that the processes and procedures are
riddled with defects, he or she will be very surprised when failures occur.
One way to become more aware of those defects is to acknowl-
edge that they are there and to regularly communicate that “we” as an
organization want to know about those defects. In the airline industry,
the need to understand defects in the system was recognized years ago
and the Aviation Safety Reporting System (ASRS) was created. Estab-
lished in 1976,21,22 this near-hit reporting system became a mechanism
for communicating concerns, close-calls, or violations of any type that
had potential safety consequences. Several key features have made the
F I G U R E 2 The Aviation Safety Reporting System (ASRS) was initiated in 1976 to provide a system for voluntary aviation occurrence
reporting in the United States, which would confer conditional immunity and encourage reporting.21,22
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73
industry-wide system highly successful. Reporting is confidential, volun-
tary, and non-punitive (see Figure 2 from ASRS website). Reports are
contributed cross-functionally by pilots, air traffic controllers, mechan-
ics, and others. And the system is administered by a third party, NASA.
It has sometimes been referred to as a “get out of jail free” card. By
making the report, the individual cannot be prosecuted or penalized.
The system and database remain in use today along with another sys-
tem called the Aviation Safety Action Program (ASAP) created in the
1990s.23,24 ASRS may eventually be phased out in favor of ASAP
because ASAP provides more data, which allows for better analytics
and objective assessment of the events.
These programs work by acknowledging that systems are not per-
fect, humans make mistakes, and sharing that information is the best
way to identify hazards and implement improvements that can reduce
the likelihood of recurrence and worse outcomes. A culture that dic-
tates “Everyone, Do it Right, Everytime” is not conducive to moving
toward this model.
My uncle, Robert M. Euwer, was a forward observer in the
Korean War.25 He was at the sharp end of the stick. His job was to go
out to identify problems and opportunities and then report back to
higher ranking commanders. There was no stigma with reporting bad
news. This was simply his job.
Changing the paradigm to a model that values hearing the reali-
ties on the ground involves both changing the language and changing
actions. Actions speak louder than words.
Managers need to ask, “How can we encourage and incentivize
employees to speak out and to show us the errors in procedures, the unu-
sable procedures, and the instances when work proceeds without a proce-
dure (and needs one) as well as instances when performing work without
a step-by-step procedure may be acceptable or preferred? What are the
barriers that could derail new programs intended to identify these flaws?”
How to get there may vary, but the goals of identifying defects,
rewarding finding those defects, and embedding continuous improve-
ment practices into the job should be fostered. The overriding theme
should be that defects are known to exist and expected to exist. The

74
goal is to find them and eliminate or mitigate them. This reality is the
basis of The Manufacturing Game, which was developed to improve
reliability through systems thinking and defect intolerance.26,27 These
ideals and this recognition apply equally to process safety.
The suggestion to “ditch the term operational discipline” and
ensure full management accountability is not intended to deflect
blame from the operator to the manager. It is an effort to move away
from blame. Defects know no boundaries. They exist because our
equipment, processes, and systems are not perfect. The system pro-
vides the bandwidth within which we can improve. So, management
must understand where we require more bandwidth. Addressing that
need requires awareness, resources, and focus. And addressing
that need will ultimately facilitate other improvements.
4.2 | Perform rigorous technical review and
validation
The organization that Rickover created demanded extremely high levels
of technical competence that was achieved through careful selection of
candidates and rigorous training, examinations, qualification, drills, and
auditing.16,28 Additionally, technical quality was and is achieved through
integrating operations and engineering support. In the Nuclear Navy,
operational procedures are technical procedures. Operating procedures
require input from skilled operators, engineering, and supervisors to cre-
ate a new procedure or to modify a procedure. These standards are well
beyond where many industries sit today. Although daunting, those gaps
reinforce the need to take steps toward instilling high-quality technical
review for all critical operational tasks.
In PSM facilities, modifications require complete technical
29–31
review no matter the size or scale of the change. Changes
include improvements to operating procedures. When operating pro-
cedures are redlined or edited, proposed changes need to be routed
through the management of change (MoC) process. Through that
process, the change requires technical review by all impacted func-
tional disciplines29 and process safety review by qualified
reviewers.30,31 Many companies handle operational procedural
changes under alternative protocol outside of the standard MoC
system. Unless the changes are purely administrative, any change to
operating procedure steps, tools used, equipment involved, and so
on, should trigger standard MoC review requirements. In processing
industries, many incidents stem from these types of procedural
changes that have not gone through review by qualified personnel
from all impacted technical disciplines.
Critical guidance procedures such as energy control/lock-out tag-
out, opening and blinding, hot work, and confined space entry should
also involve technical and process safety reviewers in addition to
review by the Health and Safety (H&S) group and Operations. And
careful auditing of front-end systems, such as workorders generated
through computerized maintenance management systems (CMMS), is
needed to find modifications that are slipping through without being
classified as changes. These misses will not be found if the auditor
does not have the required technical competencies.
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4.3 | Foster employee ownership by enabling the
workforce (at all levels)
Engaging the workforce at all levels to participate and lead in
problem-solving has been shown in many organizations to result
in better performance and outcomes, including in safety performance.
There are many good resources available online that share these suc-
cessful experiences, such as in the Sidney Dekker books and videos
on Safety Differently.32–34 These resources cite examples of compa-
nies within oil and gas, health care, retail, and food and beverage
industries where workers were empowered to craft their own safety
programs and processes. In these examples, the companies improved
their safety performance while invigorating the workforce through
their ownership in developing the processes.
Although these ideas are not new, an increasing number of voices
are advocating for engaging the workforce from the bottom up. The
notion that “people are not the problem, people are the problem
solvers” is highlighted by many leaders in the area of human and orga-
nizational performance (HOP) including Dekker,32 Conklin,14,35
Fisher,13 and Edwards.36
If the workforce is designing the system, they are more likely to
follow their own plan. Recognizing the weaknesses of New Year's res-
olutions, those plans need to be achievable and well vetted.
The difficulty in relying on employee empowerment to design
safety solutions in industries handling highly hazardous materials and
operations is that most significant process safety risks involve high-
consequence, low-probability events that workers have not seen in
their lifetime of work experience. So, there must be technical process
safety support and input on any solutions or changes that are formu-
lated by these workers.
A long-standing gap in industry is the lack of positions that com-
bine operations and process safety. How many operations personnel
attend the annual Global Congress on Process Safety (GCPS)? What
percentage of that audience comes from operations versus engineer-
ing versus other disciplines? Does your organization have an opera-
tions process safety technician? The role could support day-to-day
operational work and provide embedded technical support focused
on process safety hazards. An individual with operational background
who understands process safety implications and advocates for the
use of process safety tools could help bridge the gap. This role could
be a front-line resource to help catch misses potentially passed
through the system and could help support more thorough process
safety reviews.
Just as operator-generated ideas for improvements must be vet-
ted for technical accuracy and process safety risk, ideas conceived
from above must be vetted through frontline workers to confirm that
implementation on the ground will work. Engaging the workforce is
an essential part of that process. Management-generated ideas such
as encouraging routine redlining of procedures may sound simple, but
if there are aptitude, skills, or technology barriers that make the task
hard to accomplish, the idea may not work. Monetary incentives may
sound good, but if workers see unfairness in distributions or that the
awards do not align with value-added changes, the incentive may

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backfire. Expecting new contributions to be made by employees with-
out making the space in workers schedules may be seen as unfunded
mandates.
Go to the workers, find their pain points, and seek their ideas.
Starting the process for suggesting improvements with the personnel
doing the work, as shown in Safety Differently,32–34 is far more ener-
gizing to the workforce. Also recognize that with any change or new
initiative, trial and error should be expected. Potential solutions,
whether generated by workers or by management, must be continu-
ally revisited and tweaked or fully reinvented if they are found to be
ineffective at achieving the intended goal.
4.4 | Develop usable procedures by integrating
human factors learnings
To improve consistency in usage of and conformance with proce-
dures, the procedures need to be good. But what is good? That defini-
tion may change from time to time, but effective procedures will have
some common characteristics regarding form and format. Better prac-
tices for writing procedures have been gleaned over the years from
human performance social science,9,13 from industries that “do proce-
dures better,” and from practical field trial-and-error experience. Inter-
estingly, industries that “do procedures better” have some similarities
but also some differences.
Probably the best known example of an organization that has well-
crafted, accurate, and consistently followed procedures is the Nuclear
Navy. Most operational tasks in the Nuclear Navy are performed using
rigorously developed step-by-step procedures. The standards were set
from the outset by Admiral Rickover. That origin story is in marked con-
trast to the situation within industries such as oil and gas, refining, che-
micals, and many others where plants were built and started up before
industry and regulators recognized the need for complete and well-
maintained written procedures. Some original industry operators can
recall the date when the company retroactively enlisted procedure
writers to document what the operators did and what the operators
knew. These industries have been playing catch-up since that time.
The Nuclear Navy benefits from having the imperative and the
funds to provide robust training and to require rigorous qualification
standards for new hires. Ironically, another industry known for strong
“procedure processes” requires these practices because of the reverse
situation. McDonald's (fast food restaurants) has exemplary processes
for writing procedures, communicating procedures, and reinforcing
procedures. “Because of high employee turnover and inexperience of
new hires, McDonald's procedure and training process must be a very
robust design.37” By contrast, processing industries tend to have staff
with more baseline skills and knowledge than a McDonald's worker
but less baseline knowledge than a nuclear worker. Following the hire
date, however, the McDonald's training and qualification require-
ments likely exceed some or many processing industry training stan-
dards. During a field trip in 2002 to learn about McDonald's practices,
their personnel explained their training, qualification, certification, and
procedure processes to our team.
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75
McDonald's uses procedure writing best practices such as format-
ting and organizing documents through information mapping, minimiz-
ing words, including critical data, providing unambiguous instructions,
and using checklists. McDonald's visual systems provide easy-to-read
information in the locations where the information is needed, such as
storyboards above the counter, abbreviated laminated procedures at
workstations, and preventive maintenance and cleaning instructions
on laminated tabbed cards—stored in locations where the procedures
are used. All procedures, signs, and labeling make ample use of color
and apply consistent color coding. Equipment is designed to mistake-
proof processes. During the field trip, our team learned that the super-
visor spent 75% of his/her time on the floor coaching and learning
from employees and 25% of his/her time in his or her office, in meet-
ings, or preparing reports.
One other area of commonality between the Nuclear Navy and
McDonald's is the consistency of the “kit,” whereas the inconsistency
of the “kit” in processing industries exacerbates the challenges for
catching up on procedural improvements. Most industry procedures
are unique to the process, plant, and equipment involved. Variability
associated with organizational and personnel differences adds another
layer of specificity. These factors create more challenges for industries
playing catch-up.
Although it is a large elephant, the learnings available from other
industries, academia, and our history provide a toolbox for developing
more usable procedures.
Like risk, human error can never be eliminated. But the frequency
of mistakes can be reduced by creating procedures that apply learn-
ings on how to optimize human performance of tasks.13 To make
these improvements, personnel skilled in developing user-friendly pro-
cedures that minimize the chances of human error need to be part of
the effort.9,13
This work includes the layout, formatting, and writing of the pro-
cedure document. In addition to improvements in layout and style,
the procedures need to be carefully checked to ensure they do not
include error traps1,13 such as vague or unclear guidance, misleading
information, conflicting information, or multiple embedded steps. The
procedures should not require field decisions without providing spe-
cific guidance on how to make those decisions. Critical information
must be included directly in the procedure. Specificity helps to drive
down error rates. Vague or general guidance will drive up error rates.
Newly written or modified procedures then need to be
beta-checked for usability via a field walk-down. A completed but
unapproved procedure requires hazard assessment using a procedural
process hazard analysis (PHA) method.38,39 The procedural PHA will
identify how steps could go wrong, the causes that could lead to
errors in completing a step, the consequences from those errors, and
improvements that could prevent the error or lessen the impact of the
error. The Human Performance Oil & Gas Walk-Through Talk-
Through Guide (WTTT)40 essentially describes elements of a PHA.
Writing by Bridges and Marshall38 and Medrano39 offer guidance and
methods for conducting a procedural PHA. An effective process haz-
ard review is an embedded requirement for conducting a complete
MoC safety review under OSHA PSM.31

76
Visual indicators, visual signals, and visual controls41 represent
another form of instruction. Lean manufacturing principles, gleaned
primarily from Japan, highlighted the importance of applying visual
systems to support reliability and productivity.42 Visual systems can
be a powerful tool in supporting human performance.41 Data show
that >95% of cars stop for red lights and/or stop signs,43 which is sim-
ilar to or better than a safeguard having a risk reduction factor of
10, or probability of failure on demand of 0.1. Use of labeling, color
coding, lighted displays, signs, and other visual tools can support com-
municating key information at the location where that information is
needed. In some cases, procedural steps can be posted in the loca-
tions where they are needed, as is done at McDonald's.
Understanding how to construct a procedure and recognizing
how to avoid introducing error traps into the procedure are essential
prerequisites for moving an organization toward more consistent con-
formance and compliance with procedure use. Significant effort and
resources need to be devoted to starting and progressing on that jour-
ney. This journey does not have an endpoint. It is a continuous pro-
cess of incremental improvement and reassessment.
4.5 | Prioritize like a demon (based on defined
parameters)
All these ideas sound terrific, but who has time to do these things?
Plus, we are not building a Nuclear Navy from the ground up. We are
already in operation, and things are happening every day that require
our attention.
Working at a typical operating facility is like being on a treadmill
that never slows down. Finding the time to address systemic deficien-
cies and to make wider improvements is a real challenge given the
steady stream of fires that need fighting in most facilities.
So where to begin? … Prioritize like a demon.
In her TED Talk, Emergency Room (ER) doctor, Darria Long Gillespie,
speaks of the challenges that many people face of feeling “too busy” and
the stress that this busy-ness induces. How do ER workers do it? Her mes-
sage is extreme prioritization, or triage, triage, triage in ER vernacular.44
I have experienced the same when working in plants. After
about 5 years of working in a scattershot way and responding to the
loudest voice and the squeakiest wheel, our team implemented a
successful prioritization process that was supported by a centralized
tool for managing all incoming small project work requests. The con-
cept is simple, but it took a significant change in our tools and work
processes to bring about that needed improvement. We moved from
a process that allowed anyone to ask the engineer to start working
on their need to a centralized weekly review process supported by
our local management, supervisors, operations leads, and engineering
to determine the priorities and revisit the highest priorities each
week. Anyone could attend the meeting and lobby for their project.
But the priorities were set by the team and stood until the next
week's meeting, absent emergency break-in work that met certain
criteria. My life and probably my blood pressure improved after we
15475913, 2024, 1, Downloaded from https://aiche.onlinelibrary.wiley.com/doi/10.1002/prs.12505 by SEA ORCHID (Thailand), Wiley Online Library on [27/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
OLSEN
implemented this system. I knew that no matter how long my list
was, by starting at the top, I was working on what my team mem-
bers deemed most important. And they would understand why I was
not working on the other 89 items.
Prioritization allows people to be focused, productive, and mini-
mize stress. And the group prioritization effort maximizes the success
of the organization by targeting work on the most critical needs.
Note: Part of empowering the workforce includes enabling the
workforce. A quick way to dampen energy and enthusiasm for making
improvements is the failure to follow through. Repeated inaction or
dismissal of ideas can snuff out sharing of future improvement ideas
and impact retention of the strongest employees.
Involving the workforce in the prioritization efforts through
transparency, an open invitation, and well-publicized priorities can
help foster consensus on the best use of limited resources. At the
very least, that participation and communication may support under-
standing the constraints. Including worker-originated ideas in the
mix of projects will go a long way toward maintaining that
employee engagement and may result in key improvements. When
decisions are ultimately made to reject or indefinitely defer addres-
sing an idea, it is crucial to—at a minimum—respectfully share with
the individual the rationale for why the decision was made not to
proceed.
4.6 | Conduct failure/cause analysis early
and often
Performing failure/cause analysis (a.k.a. RCA) early and often is one of
the best tools for improving reliability and mitigating safety risk. Peo-
ple are often more receptive to acknowledging problems they have
seen than problems that may occur in the future, such as described in
hazard review scenarios. Connecting the dots between the two, such
as identifying and addressing the causes for failures of critical safe-
guards in high hazard scenarios, can help to relate those PHA scenar-
ios to real life and make them more credible to employees.
A great mechanism to empower the workforce is to engage all
team members in routine failure/cause analyses that support learning
and improvements. Workers will naturally see problems and have
ideas to fix them whether trained in RCA or not. Equipping personnel
with failure analysis tools and building a culture that rewards struc-
tured problem solving will enhance the quality of the solutions. Near-
hits and process upsets can be analyzed using the same tools that are
used for more involved incidents.45,46
The same learning and cause analysis tools can be applied to
high-risk work activities that have been incident-free to understand
the causes of success. These learning exercises may identify weak-
nesses in individual layers of protection not previously recognized.36
The weaknesses can then be addressed before an event occurs. The
process safety operational role discussed above could become a point
person for supporting the operating staff in working through failure
and cause analyses.
 15475913, 2024, 1, Downloaded from https://aiche.onlinelibrary.wiley.com/doi/10.1002/prs.12505 by SEA ORCHID (Thailand), Wiley Online Library on [27/02/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
OLSEN 77

F I G U R E 3 Real drift showing

how workers continually adapt
resulting in work-as-done versus
work-as-imagined. Deviations from
procedures have the potential to
result in positive or negative
outcomes.13

4.7 | Reward proactive continuous improvement
efforts
Many companies tend to reward the heroes that come in to save the
day during upset or emergency situations. But rewarding the smaller
proactive continuous improvement efforts by workforce members is
equally and probably more important.
Continuous improvement means finding and addressing defects
of any type that are in the system.26,27 Addressing defects includes
identifying mitigations to prevent small failures or upsets
as implementing changes to address broader systems issues that con-
tribute initiating causes or cripple safeguards. Defects include
• procedure steps that cannot be followed or should not be
followed;
• work that is progressing without a procedure;
• permitted work that is proceeding without a completed quality
safety review;
• prescribed field walk-downs that are not occurring before issuing
permits;
• MoCs involving process changes that are signed off without a com-
30,31
plete hazard review ; Initiative titles or slogans are not the most important driver, but a poor
• MoCs that are signed off without all required technical disciplines
participating in the technical reviews29;
• PSSRs that are signed off without field walk-downs47; and
• many other procedural and process defects and deviations.
Identifying those day-to-day defects and taking steps to prevent
their recurrence are key continuous improvement efforts. Identifying
these work process defects does not need to wait for a 3-year audit
to occur. Changing the language and creating mechanisms that
encourage the workforce to continuously look for defects in all
aspects of their work will drive more systemic
26,27,32–34
ments.
Note: Part of assessing a defect can include determining if a per-
ceived “defect” (i.e., deviation) is actually an
opportunity. If “work-as-done” involves “taking a short-cut” from the
written procedure steps, this situation requires technical/process
safety review to determine whether the short-cut is a defect or an
improvement (Figure 3). If the alternative steps are safe and stream-
line the procedure, it is better to institutionalize this change through
updating the procedure. If found to be unsafe, the hazards and risks
need to be communicated so that the practice is changed.
We must expect that defects exist,26,27 that humans make
mistakes,1,2,14 and that normalization of deviation is everywhere.15 In
45,46
as well short, we must realize that our processes are not perfect. The goal is
to find the defects and implement individual and systemic corrections
wherever possible and as often as possible. There are too many
defects in the system to make a dent if the entire workforce is not
engaged in and rewarded for being part of that solution.
5 | CONC LU SIONS
The term “operational discipline” and the definitions given imply that
lack of discipline is a causal factor for human error. Through failure
analysis, experience, and social science, we know that is not the case.
slogan can contribute to derailing an improvement effort. We do not
want to frustrate or talk down to workers who we need to engage in
finding solutions. It is incumbent on managers and industry leaders
who have adopted the term “operational discipline” to make the shift
away from it.
When we seek to improve organizations' reliability and safety
performance, management must acknowledge the realities of how
humans behave and the barriers to aligning that behavior with perfect
conformance. We cannot address those barriers if we do not name
them specifically. We must recognize that our organizations and pro-
improve- cesses are laden with defects. It is our job to continually find those
defects and correct them.26,27
Healthy culture requires a positive, inclusive, and curious
improvement environment that seeks to continuously learn and improve

78
without casting blame. Even if the term “operational discipline” is
not intended to place blame or point at operators, the choice of
words defeats that aspiration. When seeking to build or improve
process safety culture, choose language that supports a positive
learning environment of ownership and empowerment by the
workforce. And support those words with management actions
and accountability.
ACKNOWLEDGMENTS
The author wishes to thank session chairs Soham Dutta and David
Moore for their interest in this topic and for selecting this paper. She
wishes to thank Mark Paradies, G. Jerry Lavine, Sally Lavine, Martin
McKenna, Rob Fisher, Elliot Wolf-Stokes, Mark Humphrey, Keith
Mackey, John Cox, David Moore, Soham Dutta, Bill Mosier, Jennifer
Mize, Justin Clark, Sidney Dekker, and others for their review, com-
ment, and/or other contributions to this paper and presentation. She
appreciates having reviewers representing operations, engineering,
management, and consulting, and is grateful to have had representa-
tion from multiple industries and sectors including oil and gas, chemi-
cals, aviation, the military, nuclear utilities, and the U.S. Nuclear Navy.
Direct input by Navy veterans including persons who have served in
the Nuclear Navy is especially appreciated.
FUND ING INFORMATION
None.
CONF LICT OF IN TE RE ST ST AT E MENT
The author declares no conflicts of interest.
DATA AVAI LAB ILITY S TATEMENT
Data sharing not applicable—no new data generated.
ORCID
Jody E. Olsen https://orcid.org/0000-0003-2610-2534
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How to cite this article: Olsen JE. Why the term “operational
discipline” is not helpful, and better options for instilling
positive process safety culture. Process Saf Prog. 2024;43(1):
70‐79. doi:10.1002/prs.12505