(110a) The Roundabout Way to Disaster: Recognizing and Responding to Normalization of Deviance

Humans develop processes to structure their activities and set and reach goals. Where a process exists, there will be deviations from that process. Skipped steps, workarounds, shortcuts, improvements, and innovations can be incorporated over time, gradually resulting in new practices that are accepted as the norm. Small changes that seem insignificant can easily be overlooked and therefore not managed. As individuals, teams, and organizations tolerate non-conformance, normalization of deviation can be established. The cumulative effect of these deviations can be unmitigated hazards that can lead to a catastrophic process safety event.

A CCPS project subcommittee (Project 269) was established to develop a text to address the initial and long-term effects of normalization of deviations. The finished book, Recognizing and Responding to Normalization of Deviance, will be published in early 2018. This paper will provide examples of the depth and breadth of normalization of deviation throughout processes, procedures, and organizations, and will illustrate techniques to address its potential impact.