violations; safety; risk perception; social and cognitive rationality
Résumé :
[en] The introduction of rules and procedures to guide front-line operators’ behaviour and to decrease the frequency of errors is a growing safety strategy in complex, risk systems. It is thought to be a useful way of controlling and standardising human practices and of increasing safety and quality. However, merely developing procedures does not ensure that they are followed. In this study, observation was used to collect information on procedural violations in a pharmaceutical company. Interviews were conducted with the operators and the prescriptors to better understand how and why these violations were occurring. Results showed that a small number of procedures were breached by the majority of operators and that the rules which were violated were the ones associated with a perception of minimum risk. Results suggest the rationality of operators is a response to cognitive and social influences which must be taken into account when designing procedures.
Amalberti, R., 1996. La conduite des systèmes à risques. Paris: PUF.
Aslanides, M., et al., 2007. The evolution of error and violation descriptions in French air force accident reports: The impacts of human factors education. Human Factors and Aerospace Safety, 6 (1), 51-70.
Besnard, D. and Greathead, D., 2003. A cognitive approach to safe violations. Cognition Technology and Work, 5, 272-282.
Blockey, P.N. and Hartley, L.R., 1995. Aberrant behaviour: errors and violations. Ergonomics, 38 (9), 1759-1771.
Bourrier, M., 1999. Le nucléaire à l'épreuve de l'organisation. Paris: PUF, Le travail humain.
de Brito, G. and Veyrac, H., 1997. Categorisation des representations du prescrit et du non-respect des procedures. In: Proceedings of the XXXII symposium of the Société d'Ergonomie de Langue Française, 17-19 September, Lyon, France. Toulouse: Octares, 115-124.
Dejours, C., 1996. Prescription, transgression et souffrance dans le travail. In: J. Girin and M. Grosjean, eds. La transgression des règles au travail. Paris: L'Harmattan, Collection Language & Travail, 107-117.
de Terssac, G., 1992. Autonomie dans le travail. Paris: PUF.
de Winter, J.C.F., et al., 2007. Violations and errors during simulation-based driver training. Ergonomics, 50 (1), 138-158.
Glendon, A., 2007. Driving violations observed: An Australian study. Ergonomics, 50 (8), 1159-1182.
Kontogiannis, T., Kossiavelou, Z., and Marmaras, N., 2002. Self-reports of aberrant behavior on the roads: errors and violations in a sample of Greek drivers. Accident Analysis and Prevention, 34, 381-399.
Lawton, R., 1998. Not Working to Rule: Understanding procedural violations at work. Safety Science, 28 (2), 77-95.
Lawton, R. and Parker, D., 1999. Procedures and the professional: the case of the British NHS. Social Science and Medicine, 48 (3), 353-361.
Leplat, J., 1998. About implementation of safety rules. Safety Science, 29, 189-204.
Lindroos, O., 2009. Relationship between observed and perceived deviations from normative work procedures. Ergonomics, 52 (12), 1487-1500.
Mayen, P. and Vidal-Gomel, C., 2005. Conception, formation et developpement des regles au travail. In: P. Rabardel and P. Pastre, eds. Modèles du sujet pour la conception. Toulouse: Octares, 108-128.
Mesken, J., Lajunen, T., and Summula, H., 2002. Interpersonal violations, speeding violations and their relation to accident involvement in Finland. Ergonomics, 45, 469-483.
Norman, M.G. and Thanisch, P., 1993. Models of machines and computation for mapping in multicomputers. ACM Computing Surveys, 25 (3), 263-302.
Paries, J., 2007. Securite et facteurs organisationnels et humains dans les transports. Communication au Séminaire International: Sécurité et Sûreté de l'Exploitation Ferroviaire. Rabat: Maroc, Avril.
Parker, D., et al., 1995. Driving error, driving violations and accident involvement. Ergonomics, 38, 1036-1048.
Phipps, D., et al., 2008. Identifying violation-provoking conditions in a healthcare setting. Ergonomics, 51 (11), 1625-1642.
Polet, P., Vanderhaegen, F., and Wieringa, P., 2002. Theory of safety violation of system barriers. Cognition, Technology and Work, 4 (3), 171-179.
Reason, J., 1990. Human error. Cambridge: Cambridge University Press.
Reason, J., 2008. The human contribution. Unsafe acts, accidents and heroic recoveries. Aldershot, UK: Ashgate Publishing.
Reason, J., et al., 1990. Errors and violations on the roads: a real distinction? Ergonomics, 33 (10-11), 1315-1332.
Rimmo, P., 2002. Aberrant driving behaviour: homogeneity of a four factor structure in samples differing in age and in gender. Ergonomics, 45 (8), 569-582.
Sullman, M.J.M., Meadows, M.L., and Pajo, K.B., 2002. Aberrant driving behaviour amongst New Zealand truck drivers. Transportation Research Part F, 5, 217-252.
Stradling, S., 2007. Car driver speed choice in Scotland. Ergonomics, 50 (8), 1196-1208.
Vaughan, D., 1999. The dark side of organizations: Mistake, misconduct, and disaster. Annual Review of Sociology, 25,271-305.
Weick, K.E., 1993. The collapse of sensemaking in organizations. Administrative Science Quarterly, 38, 628-652.