Understand motives for deviation rather than only prohibiting it
Aliases: local rationality · deviation motive · functional analysis · management of change · MOC
What it is
Understanding deviation motives, at the organizational level, means building a standing channel that collects why the field departs from procedure and converts that into procedure revision, equipment or resource changes, or an explicit compliant path — typically run through a management of change (MOC) process. This is different from inferring what one operator was thinking at one moment: the organization needs not a one-off read on individual motive, but a channel that keeps moving motive information to whoever has authority to change the procedure.
Why it happens
Motive information does not surface on its own. Admitting a deviation, even a well-justified one, can land on a performance record or trigger accountability, which pushes people toward describing their actions after the fact as fully compliant. Even when information is captured, if it only shows up in accident investigations or annual audits, months have usually passed and the specific conditions — a missing part, a short-staffed shift, a scheduling conflict — can no longer be reconstructed. Two things need to hold at once: a channel that captures information soon after the deviation (field observation, structured interviews), and a formal outlet that turns what is captured into an actual change (MOC). Without the second piece, the information just sits in a file and changes nothing.
Studying it
Field observation should be done by observers who do not evaluate the people being watched, and should cover multiple shifts rather than one crew's habits. Structured interviews should probe what other options existed at the time and why the compliant route was not taken, rather than asking why the rule was not followed — the latter phrasing pushes answers toward after-the-fact justification. Cross-check accounts against logs, schedules, and equipment status records from the same period rather than treating a single account as sufficient.
Where it stops holding
This channel depends on people believing that telling the truth will not be held against them; if past handling has taught them otherwise, the motives collected will skew systematically toward explanations that sound safe, hiding real goal conflicts or competence gaps — and building the observation and interview process will not fix that distortion on its own, since the precondition of no retaliation for honesty has to be addressed first. The channel is for deviations that a procedure, equipment, or resource change can actually resolve; deliberate harm or knowing, reckless violation is not what it is meant to convert, and still needs separate accountability.
Applying it
- Sort deviations captured through observation and interviews into categories — tool/interface defect, goal conflict, understaffing, other — since each category points to a different kind of fix.
- Staff the MOC review with a fixed composition: frontline representation plus process/engineering plus safety, so the review is not a one-sided rubber stamp.
- Put a deadline on MOC review: within a set time of receiving a deviation signal, it must return one of three outcomes — revise the procedure, adjust equipment or resources, or keep the procedure and tighten enforcement — not stop at "noted."
- How to check: track the recurrence rate of the same deviation category after an MOC review closes it; if the rate does not drop, the conversion step itself is broken, and the fix the review chose needs to be checked against what was actually driving the deviation.