The Basic Cause of Safety Disasters – Gain Knowledge of Nebosh IGC @ Bangalore

What is the common element in many catastrophic safety failures, ranging from the explosion that destroyed the Challenger space shuttle in 1986 to the needless deaths of Sheri Sangji at UCLA in 2009 and Michele Dufault at Yale in April of this year?A penetrating analysis in chapter 12 of the independent experts’ report on last year’s Upper Big Branch mine disaster, in which 29 miners perished, suggests an illuminating answer: the “normalization of deviance.” (I learned of this chapter, by the way, from the blog of Jillian Kemsley at Chemical & Engineering News.) This interpretation derives from research into the Challenger disaster presented by Columbia University sociologist Diane Vaughan in her 1996 book The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA.It is important because it goes beyond the usual explanations of academic laboratory safety incidents, which often blame the lack of a safety culture. Rather, it suggests something more pernicious: the presence of cultures not only indifferent but actually inimical to good safety practices.

” ‘Normalization of deviance’ refers to a gradual process through which unacceptable practices or standards become acceptable. Individuals who challenge the norm — from within the organization or outside it — are considered nuisances or even threats,” says the report. At NASA, “flying the space vehicle with the defective part” — the famous O-ring whose failure triggered the explosion, and which engineers knew had problems — “became the norm.” At Upper Big Branch, “with similarly catastrophic results, Massey Energy engaged in a process of ‘normalization of deviance’ that, in a push to produce coal, made allowances for” many violations of accepted safety standards. Indeed, as the report’s title indicates, the explosion resulted from “a failure of basic…safety practices.”

Something similar appears to have happened at the institutions where Sangji and Dufault died. The principles of safe lab practice and machine operation have been known for decades and are easily available. The National Academies Press, for example, has published several editions of its classic manual Prudent Practices in the Laboratory. Yet both Sangji and Dufault appear to have ignored the most basic safety precautions. Both were reportedly smart and conscientious. Smart and conscientious people, however, do not generally do things that they know are forbidden and would get them into trouble with their superiors. This suggests that each thought that what she was doing — handling highly flammable materials without appropriate protective apparel; working on a lathe alone in the middle of the night — constituted acceptable behavior in the eyes of their supervisors. And this implies that the process of “normalization of deviance” had distorted the culture of their organizations.

Chapter 12 of the report details aspects of the culture prevailing at Upper Big Branch that resemble descriptions I have heard and read about various university laboratories: the overriding importance of production, whether of coal or data; the casual assumption that, because unsafe practices have not yet resulted in disaster, they will not do so in the future; an attitude of superiority to or disrespect and disregard for the officials charged with administering institutional safety regulations; the view that inspections, reporting, and training are bureaucratic “hoops” rather than procedures with, as the report says, “life and death consequences.”

“It is only in the context of a culture bent on production at the expense of safety that these obvious deviations from decades of known safety practices makes sense,” the report says of the Upper Big Branch mine. The same, safety experts have told me, may be true of far too many academic laboratories.

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