Dr. Zsuzsanna Gyenes

Presentation Abstract:

Creeping changes are the accumulation of minor changes which often are ignored or accepted as the new norm, but which over time can add up to a big change and ultimately lead to a major incident. For example, the well-known phenomenon, “normalization of deviance” fits into this category too. It means “that people within the organization become so accustomed to a deviant behaviour that they don’t consider it as deviant, despite the fact that they far exceed their own rules for elementary safety”. Past tragic events such as the fatal explosion and crash of Nimrod XV230, Space Shuttle Challenger or Columbia disasters, SHELL Moerdijk explosion, Herald of Free Enterprise, Kings Cross fire, and Texas City refinery explosion occurred in entirely different areas or industry sectors. There is, however, an aspect which is common in these cases, namely creeping changes. The theory behind creeping changes is that no industrial sites are static, there are changes made to the original design or there are changes due to ageing and degradation of equipment over time, together with organizational changes that can affect plant integrity. This presentation demonstrates the phenomenon of creeping changes via case studies from different industrial sectors. In addition, it suggests lead metrics associated with these events to help detect and monitor the changes in industrial operation, even starting at hazard identification.

Presenter Bio:

Dr Zsuzsanna Gyenes is a Senior Process Safety Expert with extensive experience in training CEO’s of high hazard industrial sites on Process Safety Leadership and Culture, implementing tools and overseeing Process Safety Management systems for industrial sites, reviewing safety reports, advising on risk reduction and performing on-site inspections. Currently being involved in Disaster Risk Knowledge Management, resilience goals and building scenarios for multi-hazard risk assessments.

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