Can proceduralization support coping with the unexpected?

Operations of safety critical industries unquestionably require a diversity of technical and organizational control measures to increase stability and predictability of the complex sociotechnical systems. Nevertheless, experiences from recent severe accidents and results of safety research have questioned the effectiveness of the prevailing safety management strategy that mainly relies on standardization and designed-in defenses. This paper discusses the identified need to balance between stability and flexibility in a concrete safety issue, i.e., proceduralization. The main research problem of our study is whether procedure guided practice can offer sufficient support for flexibility of operating activity. We shall frame our study with the help of a model that explains different aspects of procedures. We then elaborate how these different aspects were considered empirically in our 3-phase study. In the first study we interviewed 62 main control room operators and asked how they consider procedures to support balancing. In the second study we observed in detail 12 NPP operator crews' activity in a simulated loss-of-coolant accident. In a third study we inquired 5 procedure designers about their conceptions concerning procedure guidance in operator work. Drawing on either interview or behavioral data we analyzed the personnel's stance to the flexibility and stability balancing, and how the conceptions portray in the practices of procedure usage. Our results demonstrate that the operators are aware of the need for balancing flexibility and stability and consider successful balancing to represent "good" professional action. In actual action many operators, however, tend towards more straightforward following of procedures. Designers also see the capability for balancing stability and flexibility as a key operator competence but describe actual acting simply as procedure-following. According to the documents of the nuclear community, procedure-following is the ideal to be emphasized. The paper will be finished by discussing what new insights our results would provide for developing training of procedure usage and for the design of procedures.