Normalisation of Deviation
What does this mean?
There is a tendency, over time, to accept defects, faults and shortfalls as normal or as a part of normal practice. The Harvard Business Review calls this 'the normalisation of deviation'.
Think about this in terms of a worker that uses a ladder with broken rungs; the more times he climbs the ladder, without incident, the safer it seems to him. So climbing a faulty ladder becomes his 'normal' practice!
In addition, when people carry out a bad practice, and nothing bad happens immediately their natural tendency is to ignore the rules designed to keep them safe! That bad practice may go uncorrected until it combines with enabling factors and then WHAM!
FIPS 7268 Lost Time Injury (Lacerated hand)!
Description: A skidworker was undertaking QC attempting to flush-up a log end. Warm starting his chainsaw with the throttle-lock on the spinning chain made contact with the log end causing kick back. The bar flew up and lacerated his right hand, which was still in the air after pull starting.
Normalisation of deviation: Incorrect warm starting procedure (throttle lock on), incorrect stance (having the saw bar directly out front rather than pointing left).
NB: Readers are encouraged to refer to the BPG Chainsaw Use p. 10, 13-14
Enabling Factors: Starting the chainsaw in close proximity to the log ends where the tip of the bar could make contact before the chainsaw was under full control.
View this article in Health and Safety Bulletin 94