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Normalization of Deviance: How FMs Can Combat Accumulation of Risk

By Kelly Kidwell, Burns & McDonnell

It's a bright sunny morning, and the water is calm at the seaport. A small fire breaks out. Crews battle the blaze hoping to get it under control before it spreads farther throughout the docks, but the fire swiftly spreads out of control. The crews fall back to regroup and suddenly, the fire grows too large to battle effectively. A nearby shipment of ammonium nitrate ignites, starting a chain reaction strong enough to become a detonation. A shockwave spreads out from the site of the fire, blowing roofs off of buildings, shattering windows, and turning nearby vehicles into hulks of warped metal. Hundreds of people die, and thousands are injured. 

You might think this is Beirut, but this same story played out over 70 years ago in Texas City, a port near Galveston on the Gulf of Mexico. This and countless other ammonium nitrate explosions, including the West Texas Plant, Oppau (Germany), the Ocean Liberty (France), and Tiajin (China) should have all been warning signs and stories to learn from. Why does it take so long for us to learn?

Risk assessment professionals refer to the described phenomenon as "normalization of deviance," as coined by sociologist Diane Vaughn when writing about her analysis of the Space Shuttle Challenger disaster. What begins as a normal level of acceptable risk, such as the operating temperature tolerances for o-rings, eventually becomes accepted as normal. The limits of acceptable parameters expand over time as nothing goes wrong, and new limits of operation are pushed. Eventually, something does go wrong, and it is discovered that the original set risk has been exceeded as the tolerance slowly crept up over time. Similar disasters include the Deepwater Horizon oil spill, Grenfell Tower fire, and the cruise ship Costa Concordia that ran aground in the Mediterranean. Although most technical professionals should be aware of the risks associated with normalization of deviance, facilities management professionals especially must consider the multiple risks to their facilities and work to mitigate them.

So, what can FM's do to fight the normalization of deviance? The best answer is to check your SOPs and ensure all inspections are up to date. Conform to the original acceptable limits of risk outlined in the SOPs. Ensure your fire inspections are up to date; most jurisdictions send fire inspectors for code enforcement purposes once a year. The purpose of these inspections is to make sure conditions have not changed within the buildings that could affect fire/life safety. Some jurisdictions may have suspended these activities due to COVID-19. If your jurisdiction has suspended inspections or is behind, ensure fire and life safety systems' annual maintenance is up to date. FMs can also perform a walk down to ensure storage (especially of hazardous or combustible material) has not accumulated in unauthorized areas, emergency egress paths are free and clear, and other fire hazards such as daisy-chained extension cords or power strips are not in place.

So, what are you doing today to lower the risk in your facility? Capital Chapter members can log in and discuss in the comments below!


Further Reading:

Normalization of Deviance: SOP's are not a suggestion

Flight Safety Foundation: Normalization of Deviance

NASA: The Cost of Silence

Farnam Street Blog: An Introduction to the Mental Model of Redundancy

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