A systematic review of safety violations in industry

doi:10.1016/j.aap.2009.03.013

Accident Analysis & Prevention

Volume 41, Issue 4, July 2009, Pages 739-754

https://doi.org/10.1016/j.aap.2009.03.013 Get rights and content

Abstract

It is widely known that intentional non-malevolent violations of safety procedures and norms occur and evidence shows that safety violations can increase the risk of accidents. However, little research about the causes of these violations in work settings exists. To help shed light on the causes, this paper systematically reviews the empirical causes of safety violations in industry. Electronic database literature searches were performed to identify relevant articles published prior to January 1, 2007. Thirteen articles met the inclusion criteria and 57 different variables were examined as predictors of safety violations. Study settings were healthcare delivery, commercial driving, aviation, mining, railroad, and construction. The predictors were categorized into individual characteristics, information/education/training, design to support worker needs, safety climate, competing goals, and problems with rules. None of the reviewed studies examined whether violations can improve system performance or safety. Methodological suggestions and a macroergonomic framework are offered for improving future studies of the epidemiology of safety violations.

Introduction

In his seminal work Human Error, Reason (1990) noted “an important lesson to be learned … is that the term ‘error’ does not capture all the ways in which human beings contribute to accidents” (p. 194). The other contribution mechanism to which Reason was referring was through what is commonly referred to as a violation. Violations of safety rules, procedures and norms have now been the subject of extensive research, especially among recreational drivers (“recreational drivers” in this paper refers to drivers who are not driving as part of their employment) (e.g. Aberg and Rimmo, 1998, Blockey and Hartley, 1995, Parker et al., 1995, Reason et al., 1990). However, there is a limited amount of research literature that investigates rule violations in work settings, and still less exists in work settings where the causes of violations are studied. This is an alarming gap in the literature considering that some industries estimate that about 70% of their total accidents can be attributed to violations (Mason, 1997).

Perhaps part of the reason that the causes of violations have not been studied in detail stems from the idea that violations are actions taken by ‘bad’ people. That the term “violation” is common and that people hold their own colloquial definition for the concept may also have contributed to the lack of systematic research to understand both the concept and causes of violations. This paper aims to provide a specific definition for the term “violation.” Then, this paper seeks to systematically review what is currently known about the causes of safety violations in industry because efforts to secure or increase compliance with safety protocols and norms need an evidence base to guide intervention efforts. Armed with a specific definition and existing evidence about the causes of violations, this paper then re-frames violations as evidence of system problems rather than as actions taken by ‘bad’ workers.

Section snippets

Safety violations research

What is known to date about violations is that they certainly exist and that some evidence suggests they can lead to unwanted outcomes such as accidents. In studies of recreational driving, the existence of violations has been demonstrated using drivers’ self-reports (e.g. Kanellaidis et al., 1995, Shinar et al., 2001), frequently using a variation of Reason et al.’s (1990) Driver Behavior Questionnaire (e.g. Aberg and Rimmo, 1998, Blockey and Hartley, 1995, Parker et al., 1995). Driving

Violations: good or bad for safety?

Safety violations clearly exist in industry, but it remains unclear under what circumstances violations help or hurt safety. In recreational driving, it has been established that violations can lead to outcomes such as accidents (e.g. Özkan and Lajunen, 2005, Parker et al., 1995, Reason et al., 1990), though the link between safety violations and unwanted outcomes is not as firmly established in industrial settings. If violations can lead to accidents, it provides the first reason to study the

Definitions

The first step in the review was to agree upon a definition of a safety violation. Table 1 provides a list of definitions uncovered in the literature.

The fact that there is variety among the definitions can lead to different conceptualizations of “violations.” The differences between definitions used in the literature as well as the absence of definitions in much of the literature necessitate a more unified approach to the definition of violations.

The definitions uncovered in the literature

Inclusion and exclusion criteria

Inclusion criteria for articles in the systematic review were the following: (1) the study was empirical with a substantive focus (operationalized as articles that addressed violations in their title or in their abstract) on identifying variables that influence or predict violations of safety rules, (2) the subjects were employees and the violations were work-related, (3) the article was published prior to January 1, 2007, (4) the article was available either online or though the University of

Results

Table 2 provides a summary of the 13 articles that met the inclusion criteria.

Discussion

The main goal of this review was to answer the question, “What causes safety violations in industry?” Thirteen papers addressed this and 57 variables were examined as causes of safety violations. All of the reviewed studies implicitly or explicitly defined violations as an unwanted, though in some cases necessary, behavior. None of the reviewed studies examined whether violations can improve system performance and safety. With that caveat in mind, the discussion proceeds with a discussion of

Conclusion

The purpose of this paper was to provide a review of the empirical literature studying causes of violations of safety rules in organizational settings. Thirteen articles studying a variety of work settings were identified that met the review criteria, and 57 potential predictors of violations were examined. The predictors of violations appeared to be multi-factorial, and were generally related to the individual worker, the organization, the worker's task, or the organization's rules. Some of

Acknowledgements

This study was funded in part by a grant from the Agency for Healthcare Research and Quality (R01 HS013610, Karsh PI). The authors would like to thank Dr. Pascale Carayon and Dr. Douglas A. Wiegmann for helpful discussions on the topic of violations, and Dr. Todd Loushine, Emily Davenport, and Scot Barnett for their helpful suggestions. The authors would also like to thank Amy Kindschi and Emily Wixson for their help on searches and databases. Finally, the authors thank the anonymous reviewers

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A systematic review of safety violations in industry

Abstract

Introduction

Section snippets

Safety violations research

Violations: good or bad for safety?

Definitions

Inclusion and exclusion criteria

Results

Discussion

Conclusion

Acknowledgements

Organizational Behavior and Human Decision Processes

Accident Analysis and Prevention

Journal of Clinical Anesthesia

Accident Analysis and Prevention

International Journal of Nursing Studies

Journal of Safety Research

Applied Ergonomics

Accident Analysis and Prevention

Reliability Engineering and System Safety

American Journal of Infection Control

Journal of Hospital Infection

Advances in Experimental Psychology

Applied Ergonomics

Accident Analysis and Prevention

American Journal of Infection Control

Journal of Hospital Infection

Journal of Safety Research

Accident Analysis and Prevention

Journal of the American Medical Informatics Association

Applied Ergonomics

American Journal of Infection Control

Journal of Safety Research

Social Science and Medicine

American Journal of Infection Control

Transportation Research Part F

Social Science and Medicine

Journal of Hospital Infection

Safety Science

Accident Analysis and Prevention

Journal of Safety Research

Safety Science

Safety Science

Journal of Safety Research

Journal of Safety Research

Dimensions of aberrant driver behaviour

Ergonomics

Glove utilization and reasons for poor compliance by health care workers in a Nigerian teaching hospital

Tropical Doctor

The paradoxes of almost totally safe transportation systems

Safety Science

Violations and migrations in health care: a framework for understanding and management

Quality and Safety in Health Care

Protocol violations during medication administration in pediatrics

Routine and situational violations during medication administration

Compliance with building regulations in England and Wales

Structural Survey

Behavioral economics and compliance with safety regulations

Safety Science

Anaesthetists’ intentions to violate safety guidelines

Anaesthesia

Protection of healthcare workers from bloodborne pathogens

Current Opinion in Infectious Diseases

A cognitive approach to safe violations

Cognition, Technology, and Work

Can alcohol hand rubs increase compliance with hand hygiene?

British Journal of Nursing

Aberrant driving behaviour: errors and violations

Ergonomics

Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit

Infection Control and Hospital Epidemiology

Barriers pediatricians face when using asthma practice guidelines

Archives of Pediatrics & Adolescent Medicine

Work system design for patient safety: the SEIPS model

Quality & Safety in Health Care