The Weekly Reflektion 46/2026

We often believe that if we always do what we always did, we will always get what we always got. When people have performed a task many times without injury, they may begin to regard their experience as evidence that the method is safe. Then one day there is a change, or someone gets distracted, or complacent and an accident occurs.

How do you ensure that the wrong way does not become the normal way?

In March 2025, a maintenance engineer at an animal-feed manufacturing facility in Knowsley, England, suffered serious injuries while attempting to clear a blockage in a conveyor. The engineer was working a night shift when he was asked to investigate a problem with a conveyor. Rather than stopping and isolating the machinery, he reached through an opening in the conveyor casing to remove accumulated material while the machine was still running. His arm became trapped in the moving machinery, causing severe injuries to his hand and forearm. Working alone, he was unable to summon immediate assistance but eventually managed to free himself.

The subsequent investigation by the UK Health and Safety Executive revealed that the opening in the conveyor casing had been deliberately cut several years earlier to allow workers to clear blockages without stopping the machinery. Another conveyor had been modified in a similar way. Despite routine inspections and safety audits, these modifications remained in place.

This was not simply an individual making a poor decision. It was evidence of an unsafe practice that had become embedded in the organisation’s normal way of working as it had repeatedly producedsuccessful outcomes. Initially, the modification was a one-off shortcut to save time. The blockage was cleared, production continued, and nobody was injured. The next time the problem occurred, the same approach was used. Again, nothing went wrong.

The shortcut became an accepted method of working. What was initially recognised as unsafe gradually became routine, and the perceived risk diminished. The company had procedures in place requiring machinery to be isolated before maintenance. The rules existed, but actual working practices had moved away from them. Inspections and audits were superficial and of poor quality. This also contributed to the incident by relaying an acceptance that the operation was being carried out safely.

Unsafe working practices can gradually become accepted as normal, particularly when they have been repeated over time without causing an accident. Unfortunately, repeated success does not make anunsafe practice safe. It may simply mean that the conditions for an accident have not yet come together.

Normalisation of deviance rarely happens overnight. It develops through small compromises, repeated shortcuts and the gradual acceptance of practices that would once have been challenged.

What do you do to identify unsafe practices that have become part of the way you do things?