Page 13 - Common Elements - CCPS Safe Work Practice

Human Factors and The PTW System

Maintain a Sense of Vulnerability

A Sense of Vulnerability Is healthy. Just because a particular incident has not yet happened does not mean it will not
happen in the future. Just because there was a Near Miss without serious consequences does not mean that there
will be no serious consequences the next time it occurs. Just because a worker did not follow procedures or a work
permit, and an incident did not occur, does not mean that an incident will not occur the next time a procedure is not
followed. The following questions can be used to determine whether a facility maintains a sense of vulnerability.
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g s a sense of vulnerability a critical part of the mindset of every employee and contractor?
g Do people believe that “yes, it can happen here”?
g Do people believe that “yes, we have similar vulnerabilities”?

g Does management require consistency in practice from everyone in the organization?
g Are there systems in place to determine if inconsistencies in practice exist?
g Has the facility experienced Near Misses without serious consequences?
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g s it recognized that organizational overconfidence may be an unexpected outcome
from past good Process Safety performance?
g Do discussions on potential vulnerabilities take place between operations personnel and senior leadership?

Prevent Normalization of Deviance (also known as Normalization of Deviation)
Normalization of Deviance is defined by CCPS as “A gradual erosion of standards of performance as a result of
increased tolerance of nonconformance.” Normalization of Deviance was cited as a contributing cause to the
Space Shuttle Challenger disaster. Sociologist Dr. Diane Vaughan (The Challenger Launch Decision, 1996)
defined Normalization of Deviance as “The gradual process through which unacceptable practice or standards
become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social
norm for the organization.”
There are many warning signs that Normalization of Deviance may be an issue at an operating facility.
Here are the questions to ask to determine whether there is a problem.
g Are willful or conscious violations of established procedures tolerated without investigation
or without consequences for the persons involved?
g Can employees be counted on to strictly adhere to safety policies and practices when
supervision is not around to monitor compliance?

g Are practices or conditions tolerated that would be considered unacceptable under different
circumstances? For example:
• Are maintenance tasks allowed to proceed without proper SWP procedures being utilized if the work can be
done more quickly by not following procedures or if the hazardous energy involved is considered to be minor?

g Are all employees empowered to stop work and correct unsafe conditions for any situation or act deemed unsafe?
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g s plant operation outside of established safe operating limits allowed without a detailed risk assessment?
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g f plant operation outside of safe operating limit is absolutely necessary, are there defined steps that
must be taken, such as a written variance procedure?
• Do these defined steps (or variance procedure) require a detailed risk assessment
and approval from multiple levels within the organization?
• Are expectations clear that no one individual alone is permitted to determine
whether a deviation is permissible?

COMMON ELEMENTS OF PERMIT TO WORK SYSTEMS, SAFE WORK PRACTICES, AND PERMITS 13