图书简介

List of Tables xi List of Figures xiii Glossary xv Acronyms and Abbreviations xxi Files on the Web xiii Acknowledgements xxv Preface xxvii Executive Summary xxix 1. Introduction 1 1.1 The Definition of Normalization of Deviance 5 1.2 The Motivation for Writing This Book 7 1.3 Our Audience and How to Use This Book 8 1.4 How Our Worldview Affects Us When Recognizing Normalized Deviance 8 1.5 Work Process Knowledge is Essential in Determining the Existence of Deviation 11 1.6 Normalized Deviation and Traditional Process Safety Concepts 12 2. Why Examine the Phenomenon of Normalization of Deviation? 25 2.1 Introduction 25 2.2 Past Incidents Related to Normalized Deviance 27 2.3 How The Concept Of Normalization of Deviance Affects Overall Process Safety Performance 35 2.5 Can Normalized Deviation in Your Business Work Processes Affect Risk? 38 2.6 Normalization of Deviation and Management of Change 39 3. The Roots of Deviation 43 3.1 Lack of Operational Discipline 43 3.2 Insufficient Knowledge, Procedures, Training and Resources 50 3.3 Risk Versus Reward Perception 58 3.4 Overconfidence 64 3.5 Human Nature 69 4. Identifying Normalized Deviation 73 4.1 Find Trigger Words and Phrases 73 4.2 Use Your HIRA Process 74 4.3 Determine Which Engineering Activities Reveal Deviation 75 4.4 Use Behavioral Safety Techniques 76 4.5 Review Your Work Processes 77 4.6 Use Walkthroughs and Routine Inspections 84 4.7 Use Your Process Risk Audits 84 4.8 Pay Attention to Near Misses 86 4.9 Use Your Incident Investigation System 87 4.10 Evaluate Management of Temporary Changes 88 5. Techniques to Reduce Operational Normalization of Deviance 91 5.1 Reward Rigor in Your Management of Change Process 91 5.2 Leverage Your Near Miss Reports 92 5.3 Use Behavioral Safety Observation Data 93 5.4 Use Crew Discussion Sessions and Training 94 5.5 Emphasize Employee Participation 94 5.6 Encourage Open Dialogue Supporting All Workers Who Raise Normalization of Deviation Issues 98 5.7 Leverage Learning from Your PHA Process 98 5.8 Perform a Job Task Analysis for Every Job Position 99 5.9 Recognize All Who Combat Normalization of Deviation 101 6. Techniques to Reduce Organizational Normalization of Deviance 104 6.1 Troubleshooting 105 6.2 Consistently Anticipate the Human Tendency Toward Normalization of Deviation 106 6.3 Address the Systemic Issues Within the Organization 107 6.4 When to Stand Down - Halting Operations to Fight Deviation 110 6.5 Promote Transparency and Accountability 112 6.6 Adhere to Good Engineering Practices 112 6.7 Encourage Management To Use Technical Expertise 113 6.8 Executives Set the Tone 114 6.9 Summary 114 Appendix A - A Survey to Help Identify Warning Signs of Deviations 117 A.1 Leadership and Culture 117 A.2 Training and Competency 118 A.3 Process Safety Information 119 A.4 Procedures 119 A.5 Asset Integrity 119 A.6 Analyzing Risk and Managing Change 120 A.7 Audits 121 A.8 Learning From Experience 121 A.9 Physical Warning Signs 121 Appendix B - Job and Task Analysis 123 B.1 Job and Task Analysis and the Instructional Systems Design Model 123 B.2 Basic Steps for a Job and Task Analysis 123 References 127 Index 135

Trade Policy 买家须知