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Recognizing and Responding to Normalization of Deviance




Recognizing and Responding to Normalization of Deviance

CCPS (Center for Chemical Process Safety)

ISBN: 978-1-119-50668-3 September 2018 176 Pages


An essential guide for recognizing and responding to normalization of deviance to help organizations improve their process safety performance 

This book provides an introduction and offers approaches for finding and addressing normalization of deviation both in operational and organizational activities. It addresses the initial and long-term effects of normalization of deviations as seen in reduced efficiencies, reduced product quality, extended batch run time, and near miss process safety incidents which can lead to loss of containment of hazardous materials and energies.

Recognizing and Responding to Normalization of Deviance addresses how to recognize and respond to the normalization of deviation that can, and almost certainly will, occur in any ongoing operations that involves humans. The book’s primary focus is on reducing the incidence of normalization of deviation and the associated increased risk exposure due to its effects when operating chemical or petrochemical manufacturing facilities. It contains an introduction to the concept and offers approaches for finding and addressing normalization of deviation when it presents itself in both operational and organizational activities.

  • Contains guidance to assist facilities in recognizing and addressing the phenomenon of normalization of deviation
  • Provides techniques for addressing normalized deviations and techniques to eliminate waste in all manufacturing processes
  • Describes methods for identifying normalized deviation as well as where to find deviations
  • Includes techniques to reduce operational normalization of deviance and to reduce organizational normalization of deviance

Aimed at process safety professionals and consultants applying process safety risk reduction efforts in manufacturing areas, Recognizing and Responding to Normalization of Deviance is an important book for any organization that has seen its process safety performance deteriorate over time.

List of Tables xi

List of Figures xiii

Glossary xv

Acronyms and Abbreviations xxi

Files on the Web xiii

Acknowledgements xxv

Preface xxvii

Executive Summary xxix

1. Introduction 1

1.1 The Definition of Normalization of Deviance 5

1.2 The Motivation for Writing This Book 7

1.3 Our Audience and How to Use This Book 8

1.4 How Our Worldview Affects Us When Recognizing Normalized Deviance 8

1.5 Work Process Knowledge is Essential in Determining the Existence of Deviation 11

1.6 Normalized Deviation and Traditional Process Safety Concepts 12

2. Why Examine the Phenomenon of Normalization of Deviation? 25

2.1 Introduction 25

2.2 Past Incidents Related to Normalized Deviance 27

2.3 How The Concept Of Normalization of Deviance Affects Overall Process Safety Performance 35

2.5 Can Normalized Deviation in Your Business Work Processes Affect Risk? 38

2.6 Normalization of Deviation and Management of Change 39

3. The Roots of Deviation 43

3.1 Lack of Operational Discipline 43

3.2 Insufficient Knowledge, Procedures, Training and Resources 50

3.3 Risk Versus Reward Perception 58

3.4 Overconfidence 64

3.5 Human Nature 69

4. Identifying Normalized Deviation 73

4.1 Find Trigger Words and Phrases 73

4.2 Use Your HIRA Process 74

4.3 Determine Which Engineering Activities Reveal Deviation 75

4.4 Use Behavioral Safety Techniques 76

4.5 Review Your Work Processes 77

4.6 Use Walkthroughs and Routine Inspections 84

4.7 Use Your Process Risk Audits 84

4.8 Pay Attention to Near Misses 86

4.9 Use Your Incident Investigation System 87

4.10 Evaluate Management of Temporary Changes 88

5. Techniques to Reduce Operational Normalization of Deviance 91

5.1 Reward Rigor in Your Management of Change Process 91

5.2 Leverage Your Near Miss Reports 92

5.3 Use Behavioral Safety Observation Data 93

5.4 Use Crew Discussion Sessions and Training 94

5.5 Emphasize Employee Participation 94

5.6 Encourage Open Dialogue Supporting All Workers Who Raise Normalization of Deviation Issues 98

5.7 Leverage Learning from Your PHA Process 98

5.8 Perform a Job Task Analysis for Every Job Position 99

5.9 Recognize All Who Combat Normalization of Deviation 101

6. Techniques to Reduce Organizational Normalization of Deviance 104

6.1 Troubleshooting 105

6.2 Consistently Anticipate the Human Tendency Toward Normalization of Deviation 106

6.3 Address the Systemic Issues Within the Organization 107

6.4 When to Stand Down – Halting Operations to Fight Deviation 110

6.5 Promote Transparency and Accountability 112

6.6 Adhere to Good Engineering Practices 112

6.7 Encourage Management To Use Technical Expertise 113

6.8 Executives Set the Tone 114

6.9 Summary 114

Appendix A – A Survey to Help Identify Warning Signs of Deviations 117

A.1 Leadership and Culture 117

A.2 Training and Competency 118

A.3 Process Safety Information 119

A.4 Procedures 119

A.5 Asset Integrity 119

A.6 Analyzing Risk and Managing Change 120

A.7 Audits 121

A.8 Learning From Experience 121

A.9 Physical Warning Signs 121

Appendix B – Job and Task Analysis 123

B.1 Job and Task Analysis and the Instructional Systems Design Model 123

B.2 Basic Steps for a Job and Task Analysis 123

References 127

Index 135