You have probably heard of “Chronic Unease” but have you ever heard of “Chronic Normalisation”? If we break these two words down and look at the individual definitions, it should speak for itself. “Chronic” being the (continuation) long term effect and “Normalisation” defined in sociology is a set of actions or ideas considered normal and accepted.

  • When you consider the Space Challenger disaster in 1986, they accepted the risk of launching the space shuttle despite warnings from engineers regarding a safety critical O-ring possibly having a degraded performance in lower temperatures. NASA’s Teacher in Space Project – Christa McAuliffe’s parents were watching the launch when the disaster unfolded.

 

  • In November 1984 – most of the safety systems at the Union Carbide Plant in Bhopal were not functioning as they should. Valves and pipework were in poor condition, storage tanks contained materials well over the limits that procedure’s permitted. These failures resulted in a runaway reaction which created a cloud so deadly that this would become the worst industrial disaster.

Eventually, the accumulation of these warning signals with the absence of “action” resulted in two major disasters. These warning indicators did not come to the surface in one day; they are accepted over time (chronic) and when enough time passes, we become blind to these discrepancies, they become the norm (normalisation)! These two tragedies show that over time attitudes, degraded systems, poor integrity, and ignorance to procedure – ultimately resulted in catastrophe.  Acceptance of a lower standard should not be an option; in fact, opportunities should be used to verify that this is not the case – and that standards are duly and morally acceptable!

There are many opportunities to run mini “back to basic” campaigns, but we generally do not take advantage of these. A good example would be the ORA (Operational Risk Assessment) – a risk assessment that should prompt a team based discussion, inspection of Bow Ties, Performance Standards etc. which results in a quantified assessment of the degraded element. Instead of just mitigating the issue, why not do a gap analysis, rather than revert back to the normalised standard look for opportunities to improve on it. ORA’s by their nature are usually a reactive tool, but there is nothing wrong in benefiting proactively from the process!

High Reliability Organisations operate with a principle known as “Preoccupied with Failure”; if this mind-set is embedded then it is very difficult for chronic normalisation to exist.

Karl Weick, Co Author of “Managing the Unexpected”.

 

“The event can in some ways be considered as an abrupt and brutal audit: at a movement’s notice, everything that was left unprepared becomes a complex problem, and every weakness comes rushing to the forefront.”

 

Thanks for reading!                         Kevin McAughrey BSc (Hons)