2025 Community of Human and Organizational Learning 31st Annual Conference

Understanding how workers interact with procedures in real-world conditions is crucial for building resilient organizations. While procedure compliance is often emphasized in high-risk industries, this observational study at a petrochemical facility reveals that workers routinely adapt procedures to match operational realities. By analyzing 1,422 procedural steps across 40 procedures (both paper and digital), we developed and applied a systematic coding framework examining three key aspects of procedural execution: step sequence (order), execution method (action), and step completion (skips). The procedures were analyzed across three operational phases: preparation, task execution, and verification.

Our analysis revealed three distinct patterns of procedural adaptation:
1. Safety variations: Modifications to steps intended for maintaining safe operations
2. Routine adaptations: Variations stemming from established workplace practices and norms
3. Efficiency-driven modifications: Adjustments workers make during task completion

Workers deviated from strict procedural compliance approximately 33% of the time while completing their assigned tasks successfully. These adaptations showed systematic patterns: workers modified step order more frequently during main task activities (task execution phase), while following prescribed action more closely during initial setup activities (preparation phase – 94.8% adherence). Digital procedures showed potential in supporting consistent execution patterns, with 70% higher odds of steps being executed as prescribed compared to paper procedures.

These findings challenge traditional compliance-focused approaches and suggest practical implications for procedure design and system improvement:
1. Understanding which parts of procedures/systems require strict control versus flexibility based on operational patterns
2. Identifying where worker adaptations represent responses to work conditions rather than deviations/violations or non-compliance
3. Using insights from actual work patterns to inform procedure design that better supports task completion
4. Leveraging technology thoughtfully to enhance consistent execution where it matters most

This research demonstrates how analyzing patterns in everyday work can help organizations develop more nuanced approaches to procedures that balance necessary control with the flexibility inherent in complex operations. By understanding where and why workers adapt procedures, organizations can better support developing capacity while maintaining essential safety constraints.