Recognizing and Responding to Normalization of Deviance E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 260

Veröffentlichungsjahr: 2018

Beschreibung

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.

Leseprobe

This book is one in a series of process safety guideline and concept books published by the Center for Chemical Process Safety (CCPS). Please go to www.Wiley.com/go/ccps for a full list of titles in this series.

It is sincerely hoped that the information presented in this book will lead to an even more impressive safety record for the entire industry; however, neither the American Institute of Chemical Engineers, its consultants, CCPS Technical Steering Committee and Subcommittee members, their employers, their employers officers and directors, nor AntiEntropics, Incorporated and its employees warrant or represent, expressly or by implication, the correctness or accuracy of the content of the information presented in this document. As between (1) American Institute of Chemical Engineers, its consultants, CCPS Technical Steering Committee and Subcommittee members, their employers, their employers officers and directors, and AntiEntropics, Inc., and its employees, and (2) the user of this document, the user accepts any legal liability or responsibility whatsoever for the consequence of its use or misuse.

RECOGNIZING AND RESPONDING TONORMALIZATION OF DEVIANCE

CENTER FOR CHEMICAL PROCESS SAFETY OF THEAMERICAN INSTITUTE OF CHEMICALENGINEERS

New York, NY

This edition first published 2018

© 2018 the American Institute of Chemical Engineers

A Joint Publication of the American Institute of Chemical Engineers and John Wiley & Sons, Inc.

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The rights of CCPS to be identified as the author of the editorial material in this work have been asserted in accordance with law.

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Library of Congress Cataloging-in-Publication Data is available

ISBN: 9781119506713

Cover images: Wiley

Cover images: (top left): Photograph of Bhopal on cover provided by Dennis Hendershot, © 2004; (top right) Permission granted by CCPS for use of cover image adapted from Figure 3.1. All rights reserved; (bottom left) © US Chemical Safety Board. Public Domain; (bottom right and background) © ASSOCIATED PRESS/AP Images; (background): © Jasmin Merdan/Getty Images

In Memoriam

Robert (Bob) Walters

1957 – 2016

This book is dedicated to Bob Walters, whose organization skills, quick wit, access to notable quotes and technical knowledge made him a good collaborator for Recognizing and Responding to Normalization of Deviance. As President of AntiEntropics, Inc., Bob provided expert guidance and writing for a number of CCPS Books and The Business Case for Process Safety. I worked with him on several including Recognizing Catastrophic Incident Warning Signs in the Process Industries, which is now a top seller for CCPS. We will miss Bob and the contributions that he made to CCPS. He will be remembered fondly.

Louisa A. Nara

CCPS Global Technical Director

CONTENTS

Cover

Title page

Copyright page

In Memoriam

Glossary

Acronyms and Abbreviations

Files on the Web

Acknowledgements

Preface

Executive Summary

1: Introduction

1.1 The Definition of Normalization of Deviance

1.2 The Motivation For Writing This Book

1.3 Our Audience and How to Use This Book

1.4 How Our Worldview Affects Us When Recognizing Normalized Deviance

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

1.6 Normalized Deviation and Traditional Process Safety Concepts

2: Why Examine The Phenomenon of Normalization of Deviation?

2.1 Introduction

2.2 Past Incidents Related to Normalized Deviance

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

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

2.6 Normalization of Deviation and Management of Change

3: The Roots of Deviation

3.1 Lack of Operational Discipline

3.2 Insufficient Knowledge, Procedures, Training and Resources

3.3 Risk Versus Reward Perception

3.4 Overconfidence

3.5 Human Nature

4: Identifying Normalized Deviation

4.1 Find Trigger Words and Phrases

4.2 Use Your Hira Process

4.3 Determine Which Engineering Activities Reveal Deviation

4.4 Use Behavioral Safety Techniques

4.5 Review Your Work Processes

4.6 Use Walkthroughs and Routine Inspections

4.7 Use Your Process Risk Audits

4.8 Pay Attention to Near Misses

4.9 Use Your Incident Investigation System

4.10 Evaluate Management of Temporary Changes

5: Techniques to Reduce Operational Normalization of Deviance

5.1 Reward Rigor in Your Management of Change Process

5.2 Leverage Your Near Miss Reports

5.3 Use Behavioral Safety Observation Data

5.4 Use Crew Discussion Sessions and Training

5.5 Emphasize Employee Participation

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

5.7 Leverage Learning From Your Pha Process

5.8 Perform A Job Task Analysis For Every Job Position

5.9 Recognize All Who Combat Normalization of Deviation

6: Techniques to Reduce Organizational Normalization of Deviance

6.1 Troubleshooting

6.2 Consistently Anticipate The Human Tendency Toward Normalization of Deviation

6.3 Address The Systemic Issues Within The Organization

6.4 When to Stand Down – Halting Operations to Fight Deviation

6.5 Promote Transparency and Accountability

6.6 Adhere to Good Engineering Practices

6.7 Encourage Management to Use Technical Expertise

6.8 Executives Set the Tone

6.9 Summary

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

Appendix B – Job and Task Analysis

References

Index

Wiley End User License Agreement

List of Tables

1

Table 1.1

Table 1.2

3

Table 1.3

List of Illustrations

1

Figure 1.1.

Three Characteristics of Normalized Deviation

Figure 1.2.

PHA Management System Development and Maintenance

2

Figure 2.1.

Qualifying Characteristics of Normalized Deviance

Figure 2.2.

CCPS Vision 20/20

Figure 2.3.

Management of Change (MOC) System Flowchart

3

Figure 3.1.

Organizational Traits Promoting Deviation

Figure 3.2.

Three Phenomena that Enable Deviation

4

Figure 4.1.

The Process/Procedure Life Cycle

Figure 4.2.

Evaluate Operating Procedure Program Accuracy

Figure 4.3.

Procedure Cycle Work Flow Process

Figure 4.4.

The “Safety Triangle” for Incidents, Events, Near Misses, and Deviations

5

Figure 5.1.

Job Position Tasks, Subtasks, and KSAs

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ACRONYMS AND ABBREVIATIONS

AIChE

American Institute of Chemical Engineers

CCPS

Center for Chemical Process Safety

CSB

Chemical Safety Board (U.S.)

HAZOP

Hazard and Operability Study

HIRA

Hazard Identification and Risk Analysis

HRO

High Reliability Organization

ISO

International Organization for Standardization

KSA

Knowledge, Skills, and Attitudes

MOC

Management of Change

NBIC

National Board Inspection Code

NFPA

National Fire Protection Association (U.S.)

PHA

Process Hazard Analysis

PPE

Personal Protective Equipment

PSI

Process Safety Information

PSM

Process Safety Management

PSSR

Pre-Startup Safety Review

PSV

Pressure Safety Valve

RBPS

Risk Based Process Safety

RMP

Risk Management Program (U.S. EPA)

FILES ON THE WEB

Access the documents accompanying Recognizing and Responding to Normalization of Deviance using a web browser at the following URL:

www.aiche.org/ccps/resources/Norm_Devtn

The password for the file is Norm_dev2017.

ACKNOWLEDGEMENTS

The American Institute of Chemical Engineers (AIChE) wishes to thank the Center for Chemical Process Safety (CCPS) and those involved in its operation, including its many sponsors whose funding made this project possible, and the members of the Technical Steering Committee, who conceived of and supported this book project. The members of the normalization of deviation subcommittee who worked with AntiEntropics, Inc. to produce this text deserve special recognition for their dedicated efforts, technical contributions, and overall enthusiasm for creating a useful addition to the process safety concept book series. CCPS also wishes to thank the subcommittee members’ respective companies for supporting their involvement in this project.

The chairperson of the normalization of deviation subcommittee was Jennifer Mize of Eastman Chemical Company. The CCPS staff liaison was Dan Sliva. The members of the CCPS guideline subcommittee were:

Steve Arendt – ABS Group

Michelle Brown –FMC Corporation

James Caudill - Marathon Petroleum Company LP

Kelly-Ann Charles – Methanex Corporation

Joey Cranston – Albemarle Corporation

Scott Haney – Marathon Petroleum Company LP

David Hill – Occidental Chemical Corporation (OxyChem)

Greg Horton – SABIC

Patti Jones – Praxair, Incorporated

Jai Karia – Chevron Corporation

Neil Maxson – Covestro

Mikelle Moore – Buckman International, Incorporated

Louisa Nara – CCPS

Mark Paradies - System Improvements Incorporated

Michael Pelupessy – Akzo Nobel

Sara Saxena - BP

Joan Schork – Baker Engineering and Risk Consultants, Inc.

Adrian Sepeda – AIChE Emeritus

Tony Strawhun – Afton Chemical Corporation

Ken Tague – Archer Daniels Midland Co.

Karen Tancredi – Chevron

Daniel Wilczynski – Marathon Petroleum Company LP

Elliot Wolf – Syngenta

Robert J. Walter of AntiEntropics, Inc., New Market, Maryland, was the principal author and project manager for this project. After his (much too premature) death, Albert Ness of the CCPS completed editing. Sandra A. Baker was co-author and editor. Brian Kelly, CCPS contributed case studies used in Chapter 2.

CCPS also gratefully acknowledges the comments submitted by the following peer reviewers:

Salvador Avila - CCPS

Pedro A. Bonilla – CCPS

Jeffrey S. Caudill - Marathon Petroleum Company

Erin P. Collins – Jensen Hughes

Scott A. Haney - Marathon Petroleum Company LP

John W. Herber – CCPS

David E Herrick - Universidad de los Andes (Colombia)

Casey Johnson – Covestro LLC

John Kusowski - Engineering and Technical Associates, Inc.

Peter N. Lodal – Eastman Chemical

Michell L. LaFond - Dow Corning

William Mosier - Syngenta

Juliana Schmitz - Praxiar

David Thaman - PPG

Their insights, comments, and suggestions helped ensure a balanced perspective for this book.

PREFACE

The American Institute of Chemical Engineers (AIChE) has been closely involved with process safety and loss control issues in the chemical and allied industries for more than four decades. Through its strong ties with process designers, constructors, operators, safety professionals, and members of academia, AIChE has enhanced communications and fostered continuous improvement of the industry’s high safety standards. AIChE publications and symposia have become information resources for those devoted to process safety and environmental protection.

AIChE created the Center for Chemical Process Safety (CCPS) in 1985 after the chemical disasters in San Juanico, Mexico, and Bhopal, India. The CCPS is chartered to develop and disseminate technical information for use in the prevention of major chemical incidents. The center is supported by more than 180 chemical process industries (CPI) sponsors who provide the necessary funding and professional guidance to its technical committees. The major product of CCPS activities has been a series of guidelines and concept books to assist those implementing various elements of a process safety and risk management system. This concept book is part of that series.

The AIChE CCPS Technical Steering Committee recognized a significant increase in members’ concerns about normalization of deviation over the past five years. During audits and inspections, findings showed issues related to normalized deviance. For example, some members found sporadic evidence that some process drawings and other process safety information (PSI) items were not always updated in a timely fashion. Operating procedures, maintenance procedures, safe work practices, and training modules were not always subjected to management of change (MOC) when the plant configuration changed in a way that affected their content. These specific examples of deviations from adhering to established work flow processes in management system administration and implementation may not result in immediate catastrophic release, but are serious concerns. When it comes to the physical day-to-day work practices of operators, maintenance technicians, and engineers, normalized deviance creeps in when skipping a step or changing a step’s performance in a way that is not exactly as the approved work process describes becomes commonplace. The CCPS Technical Steering Committee initiated the creation of this concept book to assist facilities in recognizing and addressing the phenomenon of normalization of deviation.

EXECUTIVE SUMMARY

We have met the enemy and he is us.Pogo (by Walt Kelly)

Normalization of deviance can affect any organization, for profit, non-profit, or governmental organizations, and manufacturing or service organizations. Even a highly reliability organization (HRO) can be affected by normalization of deviance.

There is a story about the Czar’s courtyard. The Czar notices that there are two guards posted at each park bench in the royal courtyard. Why? Because 5 years before, the benches had been painted and the guards were posted to prevent the royal children from touching the wet paint. The order was never rescinded.

Leaders need to create a questioning culture, one where asking is not considered insubordination or blasphemy. Your behavior and actions as a leader are amplified to other employees as both an individual and as if they were the behavior and actions of the organization.

Normalized deviance, in Professor Diane Vaughan’s words, is “(when) people within the organization become so much accustomed to a deviant behavior that they don't consider it as deviant, despite the fact that they far exceed their own rules…”

Employees at all levels acclimatize to the deviant behavior the more often they see it or do it.

Outsiders see that the activities seem deviant.

People within the organization see the deviance as normal behavior.

In hindsight (that is, when caught), people within the organization realize that their seemingly normal behavior was deviant.

Pro-tip – Realize deviant behavior in foresight. Take appropriate action.

Other employees evaluate all decisions and associated actions by executive leadership, management, and supervisory employees, as representative of the organization’s acceptance, or non-acceptance, of normalized deviance. It is perception based. People in leadership roles should:

Take the time to evaluate each leadership decision against site, corporate, industry, and governmental guidance, rules and regulations.

Make your decisions accordingly.

Identify discrepancies in organizational systems and the organizational behavior that telegraphs the organization’s acceptance level for normalized deviance.

Reach consensus on the actions and prepare follow through actions to mitigate or support the anticipated response.

Actively recognizing and reducing normalization of deviation supports your organization’s successful implementation of techniques such lean manufacturing, six sigma, total quality management, international organization of standardization, and others. Establish a management element to address recognition and reduction of normalized deviance within your business process systems for worker safety, process safety, environmental, and quality management.

1.INTRODUCTION

Climate is what we expect, weather is what we get.Mark Twain

Individual and collective human behavior displays traits that are, in certain ways, analogous to the natural appearance and impact of weather events. Normalization of deviation is this type of human behavioral trait.

To help make the connection to this analogy, let us accept the following premise. If humans are involved in any type of goal reaching behavior, that activity involves a process. If a process exists, however formal or informal it may be, there can be deviation from that process. Whether we use a simple example, a person preparing their evening meal, or a complex example, a group designing, building, operating, and maintaining a chemical processing plant, the trait of normalization of deviation will undoubtedly appear in some measure. The consequences of such behavior need to be addressed.

We always hope the weather (that is, our situation) will be fine today. Sometimes we have advance notice of what to expect from a forecast for the weather. This is similar to the chemical plant’s most recent audit report with action items. Sometimes an unexpected weather event affects us (as will the effects of our or others’ behavioral deviance).

Normalization of deviance, like the weather, will appear and it will influence our experience. It is inevitable and can affect our goals in a negative way—unless we monitor it and react to it.

The analogy works in the following way.

The weather is sometimes beautiful all day and night. We wish it were like this every day. The process is running normally. Normalized deviance appears to be non-existent. Procedures and standards are being followed. All is well.