Most organizations have procedures that describe how work is supposed to be performed. They have standard operating procedures, job hazard analyses, lockout/tagout instructions, training materials, work rules, and written expectations. Considerable time may have been invested in developing these documents, and employees may have been trained on them repeatedly. On paper, the process often looks clear, organized, and predictable.
Then someone takes the time to watch the job being performed in the real workplace.
Step four may happen before step three. An employee may use a tool that is not mentioned anywhere in the procedure. Another employee may have developed a workaround because a particular step is difficult to complete. Equipment may have been modified since the procedure was originally written. A verification step that appears simple on paper may be far more difficult under actual working conditions. In some cases, employees may have added steps that make the process safer or more efficient.
What we begin to discover is that there can be a significant difference between work as written and work as done. That difference deserves our attention, but it should not immediately trigger blame or discipline. The existence of a gap does not automatically mean employees are careless, resistant to safety, or intentionally ignoring procedures. It means something about the work deserves to be better understood.
This distinction matters because organizations often respond to procedural deviations in exactly the wrong way. A supervisor observes an employee performing a task differently than the procedure requires, stops the work, corrects the employee, documents the deviation, and schedules retraining. The corrective action is completed, the paperwork is closed, and the issue is considered resolved. When the same deviation appears several months later, the organization may again conclude that employees are failing to follow expectations.
At some point, however, we need to consider whether we are actually correcting the problem or simply correcting the person.
Procedures Describe Work, but People Perform It
Written procedures are an essential component of an effective safety management system. OSHA standards require specific procedures for certain high-hazard activities, including hazardous energy control and permit-required confined spaces. Procedures establish expectations, communicate controls, support employee training, and help organizations create consistency in how work is performed.
A procedure, however, is ultimately an organization’s representation of how it believes a task should occur. The actual workplace is far more dynamic. Employees perform work while dealing with production demands, equipment limitations, changing environmental conditions, staffing levels, material availability, maintenance problems, interruptions, deadlines, and countless other variables that may be difficult to capture completely in a written document.
This is where the concepts often described in safety and human factors as work as imagined and work as done become valuable. Work as imagined represents how leaders, engineers, safety professionals, supervisors, and procedure writers expect a task to occur. Work as done represents what actually happens when employees interact with equipment, processes, people, and real-world conditions.
Ideally, those two versions of work closely align. When they do not, the difference provides an opportunity to learn more about the effectiveness of the system.
Understanding Why Procedural Drift Develops
Procedural drift rarely occurs overnight. More commonly, it develops through small adaptations that initially appear insignificant. Imagine a maintenance procedure that originally takes 45 minutes to complete. Over time, employees discover that one particular step appears unnecessary. Perhaps the equipment has changed since the procedure was developed, or the step was included because of a configuration that no longer exists. Someone skips the step once and nothing happens. The next time the task is performed, the same step is skipped again.
Eventually, experienced employees begin teaching newer employees the modified process. The written procedure still contains the original requirement, but the workforce has developed an unofficial version of the task. From management’s perspective, the procedure is being followed because no one has identified the difference. From the employees’ perspective, the modified method has simply become the normal way the work is performed.
The concern is not that every employee adaptation is automatically unsafe. Employees frequently modify work because they are solving legitimate operational problems. Some of those adaptations may actually improve efficiency, ergonomics, quality, or even safety. The problem occurs when these changes happen informally and without evaluating whether the modification introduces new risk or eliminates an important layer of protection.
A workaround that appears harmless may remove a control that has never seemed necessary because the specific conditions requiring that control have not occurred. This is why organizations should become curious when they discover differences between written procedures and actual work rather than immediately assuming the solution is enforcement.
A Procedural Deviation Is the Beginning of the Investigation
One of the easiest conclusions to reach during an incident investigation is that an employee “failed to follow the procedure.” Sometimes that statement is completely accurate. The employee did perform the task differently than the documented process required. The problem is that this observation describes what happened without necessarily explaining why it happened.
This is where the Finding Facts, Not Fault™ approach becomes particularly important. When a procedural deviation is identified, it should open another line of inquiry rather than close the investigation. Leaders should determine whether the employee understood the requirement, whether the procedure was readily available, whether it accurately reflected the current equipment and process, and whether the required steps were practical under actual working conditions.
The investigation should also consider whether supervisors knew employees were performing the task differently, whether production expectations influenced the decision, whether other employees used the same method, and how long the alternative process had been occurring. If five employees have performed the task the same unofficial way for three years, the issue is considerably larger than the actions of the employee involved in the latest incident.
These questions provide much more useful information than simply documenting “employee retrained” as the corrective action. The deviation itself becomes information about the safety management system. It tells us there is a difference between the system the organization believes exists and the system employees are actually using.
When Retraining Does Not Correct the Problem
Training is one of the most common corrective actions used in workplace safety. An incident occurs, an employee makes an error, and the organization responds with retraining. Training is absolutely appropriate when an employee lacks the knowledge or skill necessary to perform a task safely. If employees were never properly instructed, additional training is a logical and necessary response.
The situation changes when employees already know the expectation. Consider an employee who has been trained on the same procedure several times. The employee can explain the correct process and demonstrate it during an evaluation, yet consistently uses a different method during normal production. Another training session is unlikely to change the conditions influencing that behavior.
Perhaps the required method depends on equipment that is difficult to obtain. Maybe following every step significantly increases task time while production expectations remain unchanged. The physical layout of the work area may make the documented process awkward or impractical. Employees may have watched supervisors tolerate the shortcut for years, creating an unofficial expectation that the deviation is acceptable.
None of those conditions are corrected by another PowerPoint presentation or signature on a training roster. This is why organizations must distinguish between a knowledge problem and a system problem. When employees do not know what to do, training may be appropriate. When employees know exactly what to do but routinely choose another method, leaders need to understand what is influencing that choice.
When Deviations Become Normal
Procedural drift becomes particularly dangerous when deviations repeatedly produce successful outcomes. An employee skips a step and nothing happens. The job is completed, production continues, and no one is injured. The next time, the same decision is made with slightly more confidence. Eventually, repeated success begins reinforcing the belief that the alternative method is acceptable.
This pattern is closely related to what organizational researchers have described as the normalization of deviance. Deviations from expected practices can gradually become accepted when they repeatedly occur without negative consequences. What originally felt unusual eventually becomes routine, and the absence of an incident is incorrectly interpreted as evidence that the process is safe.
Workplaces can experience this in countless ways. A machine guard may be temporarily removed and no one gets hurt. A maintenance employee may skip part of an energy-control process and successfully complete the task. A forklift may repeatedly travel through an intersection too quickly without striking anyone. Required personal protective equipment may be ignored for a quick task because employees have performed the job hundreds of times without injury.
Each successful outcome can unintentionally strengthen confidence in the modified process. Eventually, the organization may reach the point where employees no longer view the deviation as a deviation at all. It simply becomes how the job is performed.
The absence of an injury, however, is not proof that risk is adequately controlled. Sometimes it simply means the circumstances necessary for a serious event have not aligned yet.
Leaders Need to See Work as It Actually Happens
One of the most effective ways to understand procedural drift is also one of the simplest: spend time observing work. This should be different from an audit or traditional safety inspection where employees know someone is actively looking for violations. The purpose is to understand how work actually occurs and what conditions influence employee decisions.
Leaders can select a routine task, bring the written procedure to the work area, and ask an experienced employee to demonstrate how the job is normally performed. It is important to make clear that the objective is not to catch someone doing something wrong. The objective is to understand the process from the employee’s perspective.
As the task is performed, compare the written procedure with reality. Look for steps that occur differently, areas where employees have to improvise, tools or resources that are difficult to obtain, and parts of the procedure that create unnecessary complexity. Ask what happens when the process does not go as planned and what conditions make performing the job safely more difficult.
These conversations can reveal information that traditional audits frequently miss. An organization may discover an unsafe shortcut that needs immediate correction. It may also discover that employees have developed a better method that should be evaluated and formally incorporated into the procedure. Both discoveries create an opportunity to strengthen the system.
Employees Need to Be Part of Procedure Development
OSHA’s Recommended Practices for Safety and Health Programs emphasize worker participation because employees often possess knowledge about workplace hazards and processes that management does not. The people closest to the work see variations, challenges, and emerging hazards every day. That knowledge should be incorporated into how procedures are developed and reviewed.
This does not mean employees independently decide which safety requirements they want to follow. Regulatory requirements, engineering principles, manufacturer requirements, and established safety controls remain essential. Instead, it means effective procedure development should combine technical expertise with operational reality.
A safety professional may understand the regulatory requirements. An engineer may understand the equipment and its design limitations. A supervisor understands production demands. The employee performing the task understands what happens when equipment jams during the middle of a shift, production is behind schedule, staffing is limited, and the tool specified in the procedure is unavailable.
A strong system needs all of those perspectives. When procedures are created exclusively from the office without meaningful involvement from the employees performing the work, organizations increase the likelihood that gaps will develop between expectations and reality.
Make the Safe Way the Practical Way
There is a larger systems lesson behind procedural drift. If an organization expects a behavior to occur consistently, the work system should support that behavior. When following the required safety process forces employees to overcome unnecessary barriers every time they perform a task, leaders should not be surprised when workarounds eventually develop.
Good system design makes the desired behavior easier. Required tools should be readily available. Procedures should be accessible, understandable, and current. Equipment should support safe operation. Production expectations should be realistic. Supervisors should reinforce the same expectations communicated by leadership, and employees should have an effective way to raise concerns when procedures no longer match reality.
This does not eliminate individual accountability. Employees still have a responsibility to follow established safety requirements, report concerns, and stop when conditions create unacceptable risk. However, accountability is more effective when organizations also accept responsibility for designing systems that support the behaviors they expect.
Safety becomes much more sustainable when employees are not routinely forced to choose between doing the job efficiently and doing the job safely.
Turning the Concept Into Action
Organizations do not need a major initiative to begin examining the difference between work as written and work as done. Start with one routine task that is relatively complex, has experienced repeated issues, or relies heavily on employee judgment. Take the current written procedure to the work area and ask an experienced employee to walk through the job exactly as it is normally performed.
Observe the process before attempting to correct it. Compare each part of the procedure with what actually occurs and discuss the differences with the employee. Determine whether steps have been changed, added, removed, or reordered and why those adaptations occurred. Ask whether equipment or production conditions have changed since the procedure was written and whether employees have developed workarounds that leadership may not know about.
Once the differences are understood, involve the appropriate employees, supervisors, safety professionals, engineers, maintenance personnel, or other subject-matter experts in determining the appropriate response. Sometimes the actual work needs to change. Sometimes the procedure needs to change. In many situations, both require adjustment.
The final step is closing the loop. Update procedures when appropriate, communicate the changes, provide training when necessary, and return to the work area later to verify that the revised process actually works. A procedure should not be considered successful because it looks correct on paper. It is successful when it accurately supports safe work in the environment where that work occurs.
Moving Beyond Compliance Means Understanding Reality
Discovering that employees are not following a written procedure should concern an organization, particularly when the deviation involves a critical safety control. However, that discovery should also create curiosity. There is something happening between the system the organization designed and the work employees are actually performing, and simply instructing employees to follow the procedure may temporarily close that gap without explaining why it existed.
Organizations that move beyond compliance approach these situations differently. They spend time where work occurs, ask questions before reaching conclusions, involve employees in identifying solutions, and examine whether the system supports the behaviors leadership expects. They recognize that procedural compliance is important, but sustainable safety performance requires understanding why people make the decisions they make within the conditions they are given.
Sometimes the employee needs additional coaching or training. Sometimes a procedure has become outdated. Sometimes equipment needs to be modified, resources need to be improved, or production expectations need to be reconsidered. Frequently, several factors contribute to the gap and must be addressed together.
The purpose of this approach is not to excuse unsafe behavior or eliminate accountability. It is to create better accountability by understanding enough about the work to prevent the same conditions from producing the same outcome again.
Written procedures tell leaders how work is supposed to happen, while employees can show them how it actually happens. The strongest safety systems understand both—and continually work to close the gap between them.
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