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xi | |
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xiii | |
Glossary |
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xv | |
Acronyms and Abbreviations |
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xxi | |
Files on the Web |
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xxiii | |
Acknowledgements |
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xxv | |
Preface |
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xxvii | |
Executive Summary |
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xxix | |
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1 | (24) |
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1.1 The Definition of Normalization of Deviance |
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5 | (2) |
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1.2 The Motivation for Writing This Book |
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7 | (1) |
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1.3 Our Audience and How to Use This Book |
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8 | (1) |
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1.4 How Our Worldview Affects Us When Recognizing Normalized Deviance |
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8 | (3) |
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1.5 Work Process Knowledge is Essential in Determining the Existence of Deviation |
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11 | (1) |
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1.6 Normalized Deviation and Traditional Process Safety Concepts |
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12 | (13) |
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2 Why Examine the Phenomenon of Normalization of Deviation? |
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25 | (18) |
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25 | (2) |
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2.2 Past Incidents Related to Normalized Deviance |
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27 | (8) |
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2.3 How The Concept Of Normalization of Deviance Affects Overall Process Safety Performance |
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35 | (3) |
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2.5 Can Normalized Deviation in Your Business Work Processes Affect Risk? |
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38 | (1) |
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2.6 Normalization of Deviation and Management of Change |
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39 | (4) |
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43 | (30) |
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3.1 Lack of Operational Discipline |
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43 | (7) |
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3.2 Insufficient Knowledge, Procedures, Training and Resources |
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50 | (8) |
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3.3 Risk Versus Reward Perception |
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58 | (6) |
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64 | (5) |
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69 | (4) |
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4 Identifying Normalized Deviation |
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73 | (18) |
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4.1 Find Trigger Words and Phrases |
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73 | (1) |
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4.2 Use Your HIRA Process |
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74 | (1) |
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4.3 Determine Which Engineering Activities Reveal Deviation |
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75 | (1) |
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4.4 Use Behavioral Safety Techniques |
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76 | (1) |
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4.5 Review Your Work Processes |
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77 | (7) |
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4.6 Use Walkthroughs and Routine Inspections |
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84 | (1) |
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4.7 Use Your Process Risk Audits |
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84 | (2) |
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4.8 Pay Attention to Near Misses |
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86 | (1) |
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4.9 Use Your Incident Investigation System |
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87 | (1) |
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4.10 Evaluate Management of Temporary Changes |
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88 | (3) |
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5 Techniques to Reduce Operational Normalization of Deviance |
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91 | (13) |
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5.1 Reward Rigor in Your Management of Change Process |
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91 | (1) |
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5.2 Leverage Your Near Miss Reports |
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92 | (1) |
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5.3 Use Behavioral Safety Observation Data |
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93 | (1) |
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5.4 Use Crew Discussion Sessions and Training |
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94 | (1) |
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5.5 Emphasize Employee Participation |
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94 | (4) |
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5.6 Encourage Open Dialogue Supporting All Workers Who Raise Normalization of Deviation Issues |
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98 | (1) |
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5.7 Leverage Learning from Your PHA Process |
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98 | (1) |
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5.8 Perform a Job Task Analysis for Every Job Position |
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99 | (2) |
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5.9 Recognize All Who Combat Normalization of Deviation |
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101 | (3) |
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6 Techniques to Reduce Organizational Normalization of Deviance |
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104 | (13) |
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105 | (1) |
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6.2 Consistently Anticipate the Human Tendency Toward Normalization of Deviation |
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106 | (1) |
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6.3 Address the Systemic Issues Within the Organization |
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107 | (3) |
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6.4 When to Stand Down - Halting Operations to Fight Deviation |
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110 | (2) |
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6.5 Promote Transparency and Accountability |
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112 | (1) |
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6.6 Adhere to Good Engineering Practices |
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112 | (1) |
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6.7 Encourage Management To Use Technical Expertise |
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113 | (1) |
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6.8 Executives Set the Tone |
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114 | (1) |
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114 | (3) |
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Appendix A A Survey to Help Identify Warning Signs of Deviations |
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117 | (6) |
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A.1 Leadership and Culture |
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117 | (1) |
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A.2 Training and Competency |
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118 | (1) |
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A.3 Process Safety Information |
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119 | (1) |
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119 | (1) |
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119 | (1) |
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A.6 Analyzing Risk and Managing Change |
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120 | (1) |
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121 | (1) |
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A.8 Learning From Experience |
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121 | (1) |
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A.9 Physical Warning Signs |
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121 | (2) |
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Appendix B Job and Task Analysis |
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123 | (4) |
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B.1 Job and Task Analysis and the Instructional Systems Design Model |
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123 | (1) |
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B.2 Basic Steps for a Job and Task Analysis |
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123 | (4) |
References |
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127 | (8) |
Index |
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135 | |