Failures do not happen overnight
Apr 26th, 2017
Jim Rohn’s quote “Failure is not a single, cataclysmic event. You don’t fail overnight. Instead, failure is a few errors in judgment, repeated every day”. That quote struck a chord with the recent failure at Oroville dam, as indeed failures do not happen overnight.
Author: Dale Kolke / California Department of Water Resources
In Oroville dam “sudden” crisis we can quote various historic deviances
Here is a tenative list of historic deviances:
- Oroville Dam annual inspections carried by State of California Division of Safety of Dam found water “seepage” on the face of the dam and warned about potential structural steel failures since 2014.
- Emergency Spillway: Insufficient drainage apron maintenance and protection
- Hyatt Powerplant: one turbine down for “routine” maintenance for four years
- Thermalito Powerhouse: 114MW capacity unrepaired for five years since fire
- Dam/River bypass Valve: decommissioned and not repaired for eight years, and finally
- Outlet Works Cracks: Apparently concerns with Tendon Anchors nearing end of design life
This list looks a lot like an example drawn from Jim’s quote or, as we would call it in risk adviser glossary: normalization of deviance.
Failures do not happen overnight.
When we perform a Risk assessment, or the review of one prepared by others, we usually carry out inquiries with key personnel. Key personnel covers key figures, not just management. We keep wondering at how this simple technique is efficient in delivering “untold truths”. That is especially true when compared to the usual workshops where alpha-dogs dominate the room.
The inquiries are also good for understanding the system under consideration. Defining the system is indeed paramount. That is especially since normalization of deviance can creep up and transform a perfectly functional system into a deficient one unbeknownst to people close to the system itself.
Examples of catastrophes due to normalization of deviance are:
- The Upper Big Branch Mine disaster. The disaster was the worst in the United States since 1970 ,
- the explosion that destroyed the Challenger space shuttle in 1986 and finally
- the cruise ship Costa Concordia crash.(2012) N.B. Negligence of the Captain and crew were the cause of the sinking. However their negligent actions were all possible because of the normalization of deviance in the cruise business and in particular on the ship itself.
So, how do we solve this?
Below are a few pointers to a solution.
Do you keep track of near misses in a database that can be cross checked by type of hazards, threats-from and threats-to?
Those data are important to detect normalization of deviance.
To do this a proper definition of “business as usual” is important as well as “force majeure” and out of norm event.
Defining success criteria and their mirror image, i.e. the failure criteria is paramount. Without these clear definitions any attempt to evaluate performances, operational and tactical risks will be vane.
If your risk register have automatic triggers that update the values of likelihood (probability) and consequences after each event or at predefined time interval, you are in control!
Your risk register should fully empower you to act where you need to maximize efficiency and give you a clear road map.
Tagged with: crisis, normalization of deviance, Oroville Dam, Risk Assessment
Category: Crisis management, Probabilities, Risk analysis, Risk management