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The Roundabout Way to Disaster: Recognizing and Responding to Normalization of Deviance

机译:灾难的争论方式:识别和响应偏差的标准化

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Humans develop processes to structure their activities to set and reach goals. Wherever a process exists, there will be always 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. To the extent that individuals, teams, and organizations tolerate nonconformance, normalization of deviation can be established. The cumulative effect of these deviations may 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 article 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. (c) 2018 American Institute of Chemical Engineers Process Saf Prog 38: e12014, 2019
机译:人类开发流程来构建他们的活动,以设定和达到目标。无论进程存在,都会始终偏离该过程。跳过的步骤,解决方法,捷径,改进和创新可以随着时间的推移而纳入,逐渐导致被接受的新实践作为常态。似乎微不足道的小变化很容易被忽视,因此没有管理。在个人,团队和组织容忍不合格的情况下,可以建立偏差的标准化。这些偏差的累积效果可能是无与伦比的危害,可以导致灾难性的过程安全事件。建立了一个CCP项目小组委员会(项目269),以制定文本,以解决偏差的初始和长期影响。完成的书籍,认识和响应偏差的正常化,将于2018年初发布。本文将在整个过程,程序和组织中提供偏离偏差的深度和广度的示例,并将说明解决其潜在影响的技术。 (c)2018美国化学工程师研究所流程SAF PROG 38:E12014,2019

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