Non-conformance analysis

Non-compliance classification focuses on three different forms of non-compliance:

1. Situations in individuals DO NOT KNOW that they are violating an accepted rule or procedure. This occurs if workers receive inadequate training or if they are not informed about changes in applicable regulations.
2. Situations in which individuals and teams CAN NOT COMPLY. This occurs if operators or managers are denied the necessary resources to meet their obligations.
3. Situations in which there is a decision not to follow rules and procedures. Individuals and teams may explicitly or implicitly decide that they WILL NOT COMPLY with an applicable regulation.

Categories of Non-Compliance

1. DO NOT KNOW

1.1 Never Knew

Poor training or a failure to disseminate regulations to the appropriate recipients

1.2 Forgot

Individual factors, inadequate reminders or unrealistic assumptions on the part of an organisation about what can be recalled, especially under stress.

1.3 Did not understand

Lack of experience or lack of guidance in how to apply information that has already been provided.

2. CAN NOT COMPLY

2.1 Scarce Resources

Often used to excuse non-compliance. Investigators must be certain that adequate resources were requested.

2.2 Impossible

Organisations may impose contradictory constraints so that it is impossible to satisfy one regulation without breaking another.

3. WILL NOT COMPLY

3.1 No penalty or no reward

There may be no incentive to comply with a requirement and hence there may be a tendency to ignore it.

3.2 Disagree

Individuals and groups may not recognise the importance of a requirement and so may refuse to satisfy it. Local knowledge may suggest that a regulation threatens safety.

It is worth recalling that causal factors are distinguished using the question: would the incident have occurred if this event or condition had not held?
Root causes satisfy the additional condition that they must represent a more general cause of future failures.
Non-compliance analysis can be used to distinguish root causes from causal factors because each of the categories above corresponds to a pre-defined set of more general root causes. By classifying a causal factor according to one of these categories, investigators are encouraged to recognise the wider problems that may stem from the associated root causes.

• Causal factors that fall into the DO NOT KNOW class represent a failure in the training and selection of employees.
• The CAN NOT COMPLY class represents root causes that stem from resource allocation issues.
• Causal factors associated with the WILL NOT COMPLY class represent a managerial failure to communicate safety objectives.

This approach offers a number of potential benefits for organisations whose activities are governed by well-documented guidelines, standards and regulations.

Difficulties Using Non-Compliance Analysis

There a number of practical problems that complicate the use of non-compliance analysis as a means of identifying more general root causes from causal factors:

1. The more general root causes that are associated with the categories in table 1 do not cover all of the potential root causes of adverse incidents in many different industries. Therefore, this form of analysis restricts the investigator to a very limited set of factors associated with training, resource allocation, and the communication of safety priorities.
2. Often it is difficult to determine whether or not particular regulations and policy documents are applicable to particular projects. Different departments often modify organisation documents to support their particular activities.
3. There may be genuine uncertainty within an organisation about whether or not an individual should have complied with particular regulations. It is easy in retrospect to argue that an incident occurred, therefore a regulation was violated; but is is not so easy to determine whether any individuals would have agreed with that analysis BEFORE the incident took place. This hindsight bias is a particular danger where non-compliance analysis is used or abused as way to attribute blame.

Table Design for Non-Compliance Analysis

Practice Non-conformance Analysis

• Using the incident of a fall from a wheelchair, draw the non-conformance analysis table Patient fall from wheelchair
• Apply your findings to your ECF diagram(s) for the incident