When Procedures Don't Match Reality
“Work as Imagined vs. Work as Done, and why the gap between them is one of the most under examined risk in your safety system.”
The Real Issue
In every organisation I have worked with, the same gap seems to exist. The procedure says one thing. Reality says another. The deadline is real, and the team on the ground is experienced enough to make the call themselves. "So they do. Every single day."
"Nobody wrote that down. Nobody needs to. Everyone just knows."
Most of the time, it works out fine. Until the one time it doesn't! and when investigators arrive, they find a deviation from procedure. What they rarely ask is: why did the procedure and reality diverge in the first place?
The Core Insight
Erik Hollnagel described this gap as the difference between “Work as Imagined” and “Work as Done.” Work as imagined is the world of safe work method statements, permits to work, and safety induction programs. Work as done is what actually happens when real people, under real pressure, deal with real conditions on the ground.
"The gap between how safety is designed and how it is performed is not a compliance failure; it is a signal. And most organisations are not listening to it."
Work as imagined
All hazards identified upfront
Procedures followed step-by-step
Supervisors always accessible
Workers stop when unsure
Lives in the safety management system
Work as done
Hazards emerge mid-task
Steps adapted to real conditions
Decisions made without escalation
Stopping feels costly or career-risky
Lives in people's judgment and habits
Why It Matters in Safety
The gap itself is not always dangerous. Workers adapting intelligently to conditions is a sign of skill and experience, it is often what keeps operations running safely when reality does not match the plan. The danger is when safety leaders design interventions, write new procedures, or conduct investigations based entirely on the imagined version.
You end up adding more paperwork to a process that was already being bypassed. Training people for the task as written, not the task as performed. And after an incident, blaming the individual for not following the procedure, sometimes without ever asking why following it felt impossible in that moment.
This is how organisations accumulate what Diane Vaughan calls "Normalised Deviance", workarounds that quietly become the standard way of working, invisible to leadership, until they contribute to something serious.
What To Do About It
Do field leadership visits, not inspections. Go to where the work happens, not to check compliance, but to understand it. Ask workers to walk you through what they actually do. “The gap between their answer and the procedure is your most valuable safety data.”
Make it safe to surface adaptations. When a worker improvises a path around a flawed procedure, they are showing expertise, not breaking rules. If the only response is disciplinary, that knowledge disappears underground. Create a safe space to hear it instead. "A blame culture doesn't make work safer. It makes unsafe work harder to see."
Investigate near-misses for system gaps, not human error. When someone deviates from a procedure and nearly gets hurt, the question should not be "why didn't they follow the steps?" It is: "what made the steps feel unworkable in that situation?" That is where the real fix lives.
Involve workers in developing procedures."If the people doing the work didn't contribute to writing the procedure, it's already out of date". A safe work method statement written only by engineers and safety professionals will always drift from reality. The frontline workers who actually perform the task, know where the friction is, what conditions vary, and where the procedure will break down.
The Key Takeaway
Every serious incident often contains a moment where the work as imagined and the work as done were two different things, and nobody noticed, or nobody felt safe saying so. Closing that gap is not about stricter enforcement. It is about building the kind of trust and curiosity that makes the real work visible.
The safest organisations are not the ones with the best procedures. They are the ones that know the difference between their procedures and reality; and keep working to close it.
I'd love to hear from safety professionals and operational leaders in the comments. Where have you seen the biggest gap between your safety procedures and what actually happens on the ground, and what did you learn from it?
If this resonates, the book goes deeper. Click the LINK to explore leadership "beyond compliance."
