Are Rules Squelching Safety? Continued from page 37 consequences when it comes to safety performance and compliance. Realize though, that safety performance and organizational performance share a lot of the same concepts, so although we’ll focus on safety here, we aren’t doing so in a vacuum. Why do we need rules? Before we find ourselves too far down this path, let’s first say that rules—some rules—are an indis- pensable part of managing any organization, and certainly one in a high-consequence industry like aviation. In almost all organizations, rules—which for the purposes of this article include all formal writ- ten rules and procedures—exist for one of three reasons: they provide a structure for organizational control; they serve as a form of organiza- tional coordination; or they function as a way to collect and disseminate institutional knowledge. Each of these three purposes is legitimate, but each brings with it associated challenges. When rules exist as a means of control, there is an inherent bureau- cratic tendency; and a long-held belief in management theory circles is that rules tend to be self-perpet- uating. This creeping expansion of rules isn’t always bad, because in this use, rules support decision-making by providing a known solution to a specific problem; but, the side effect is a reduction in autonomy by reduc- ing an operator’s freedom to choose appropriate action. Bureaucratic organizations most often shy away from informal control mechanisms (like tribal knowledge or tradi- tion) and instead try to minimize day-to-day uncertainty through Aviation Business Journal | 4th Quarter 2015 standardization and central plan- ning. In practice, these informal methods can run rampant, and in response to changing requirements (audit standards are an example) many organizations turn to rules as a solution for compliance with a standard, thereby sacrificing flex- ibility to cope with fluid operations. Rules also provide a means for defining responsibilities in an orga- nization, because they can support a common understanding among employees that allows smoother coordination under the conditions of the rule. Keep in mind that rules include things like distinct processes or procedures that define roles and accountabilities as work is completed. Although research and experience clearly show that following rules collectively is a valuable coordina- tion practice, the opposite is also true. When unique events crop up, breaking protocol as a group can also be a useful way to respond to circumstances that do not fit neatly within the bounds of procedure. Finally, rules are an excellent way of collecting and organizing orga- nizational knowledge. Rules play an important role in supporting an organization’s culture, by collecting and organizing information that has been passed down as useful enough to teach to new members. Instead of responding to each problem with a new solution, rules allow members of an organization to take advantage of collective experience and duplicate past successes. However, even though rules provide a framework for captur- ing experience, they cannot store tacit knowledge or abstract, skill-based heuristics, which are less about what gets done than they are about how it gets done despite uncertainty. The trouble with rule- based systems While we’ve established that rules can be good, and even necessary, there are a few limitations that can have a big impact on our business— and on safety performance. Rules, especially those that have to do with safety specifically, create a sort of gravitational pull for many organi- zations who view rulemaking as a relatively simple solution to complex safety issues. Most aviation organiza- tions tend to err on the side of caution with rulemaking, and they over- proceduralize in an effort to avoid what might be viewed as unwar- ranted lenience. At the extreme end of the scale, organizations may begin creating excessive rule-based con- trols as a way to protect themselves from even the slightest possibility of being blamed for a failure. In this context, the rules themselves are hol- low, and even good ones quickly get lumped in with the bad and dismissed as fodder. Even when the draw to create rules results in formalizing knowledge, this often comes at the expense of the informal, traditional knowledge. In recent history, this discussion has been a prominent one after accidents, such as Air France 447, TransAsia 235, and Asiana 214, where the concept of “stick-and- rudder” flying skills was identified as deficient by many investigators. That deficiency is certainly not in the absence of formal rules, policies, regulations, and procedures, many of which are useful in their own right. Continued on page 40 39
