Don’t let your organisation drift into failure
THE previous three articles in this series focussed on understanding and maintaining the basis of safety for our processes – identifying what could go wrong, establishing measures to prevent or mitigate hazardous events, and maintaining those measures through operational discipline. However, even organisations with strong operational discipline can drift unknowingly into a major process incident. It is important to understand how this can happen in order to try and prevent it.
Can you imagine a major hazards chemical plant, processing large quantities of toxic chemicals and flammable hydrocarbons, where operators are told to shut down the plant if the wind speed rises above 20 mph? It sounds strange, but I experienced such a situation. How could that have happened? The plant – originally built in in the 1970s – was supported in an open steel structure.
Several months before I visited, management had started a programme of re-painting the structure. But preparatory work revealed significant metal loss under the existing paint. Management was concerned but wanted to continue the work without shutting down the plant and removing the inventory. As preparation work continued, more metal loss was revealed, generating more concern. Studies were commissioned with structural engineering consultants, seeking assurance that there was minimal risk of structural failure; these were regularly reviewed, and up-dated as further metal loss was uncovered, until it was shown that the structure could possibly be de-stabilised by strong winds. This led to the introduction of supporting scaffolding in parts of the structure and the decision to stop production in the event of high wind. The re-painting programme was eventually completed, with a few production interruptions, but fortunately without a structural failure event.
This is an example of what is now known as the normalisation of deviance; a concept that was developed during analysis of the 1986 Challenger Space Shuttle Disaster to describe the slow, incremental deterioration in the basis of safety within a technically competent and safety-conscious organisation. The phenomenon is often associated with “groupthink” within management teams, where the desire for harmony or conformity within the team (and of course the desire for production!) results in dysfunctional or irrational decision-making.
Diane Vaughan, who developed the concept of the normalisation of deviance in her book The Challenger Launch Decision1 (in my view one of the best books that has been written on process safety management) describes it in relation to Challenger like this:
“No extraordinary actions by individuals explain what happened: no intentional managerial wrongdoing, no rule violations, no conspiracy. The cause of the disaster was a mistake embedded in the banality of organisational life and facilitated by an environment of scarcity and competition, elite bargaining, uncertain technology, incrementalism, patterns of information, routinisation, organisational and interorganisational structures, and a complex culture”.
Aspects of this definition very much applied to the story I outlined above. A technically competent organisation was managing a difficult and changing situation to the best of its ability, balancing risk against production. But little-by-little the basis of safety was being undermined, and at no point did anybody ask: “If this all goes wrong, what will it look like on the front pages?” This is a powerful question that Jan Hayes, in her study of high hazard organisations2, found to be used to try and combat the normalisation of deviance and “groupthink”. She used the novel term “pre-mortem” to describe it.
Detailed understanding of the basis of safety, including the design and operating limits of process plant and equipment, is obviously fundamental; only with this understanding can we be aware that the process may be drifting towards or beyond these limits. (Developing the basis of safety was covered in a previous article in this series). Robust management of change and operational risk assessment3 processes are then required to ensure that the potential impacts of planned and unintended changes respectively, are assessed thoroughly. Important aspects of these processes in relation to fighting the normalisation of deviance are diversity of views and independence. Diversity of views might mean assessment by multi-disciplinary teams or even seeking views from other sites. Independence might mean endorsement by functional technical authorities, process safety specialists or external experts. But, no matter how many engineers we involve or experts we consult, any of us can ask: “What’s the worst thing that could happen if things continue to deteriorate and how would that look on the TV news?” to prevent a drift into failure.
Another aspect of fighting complacency and drift is to establish and maintain a state of “chronic unease” in the organisation by means of appropriate process safety performance indicators, and this will be the subject of the next article in this series.
1. The Challenger Launch Decision – Risk Technology, Culture and Deviance at NASA, Diane Vaughan, University of Chicago Press 1996, 2016, ISBN 978022634823.
2. Operational Decision-making in High-hazard Organisations, Jan Hayes, Ashgate, 2013, ISBN 978-1-4049-2384-3.
3. Guidance on the Conduct and Management of Operational Risk Assessment for UKCS Offshore Oil and Gas Operations – Issue 1, Oil and Gas UK, 2012, ISBN 1-903-003-77-5.
IChemE’s Fundamentals of Process Safety course provides more detailed explorations of this topic.