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The Normalization of Deviance


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This is a presentation I gave at a staff meeting of the Boeing Shared Services International Accounting group on a topic related to safety. I chose this topic after reading about it in an article on business ethics from the Atlantic Monthly that someone had left in the microwave area. Although the article was mainly about ethics, I believe that the subject of Normalization of Deviance is at least as much related to work-related safety.

Published in: Engineering
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The Normalization of Deviance

  1. 1. The Normalization of Deviance Robert Rosen 8/4/2016
  2. 2. 2 Original source • The Challenger launch decision : risky technology, culture, and deviance at NASA Diane Vaughan, Professor of Sociology at Boston College, 1996
  3. 3. 3 Definition “The gradual process through which unacceptable practice or standards become [treated as] acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.”
  4. 4. Copyright © 2016 Boeing. All rights reserved. 4 “Over time, if we take risks and get the false feedback that we can get away with the behaviour, we learn to believe that it’s okay to deviate from a standard. “ -- Alan D. Quilley, President of Safety Results, Ltd, Alberta “Managers’ response when some aspect of operations skews from the norm is often to recalibrate what they consider acceptable risk” -- Harvard Business Review, April 2011
  5. 5. Copyright © 2016 Boeing. All rights reserved. 5 Once you think it becomes acceptable to deviate from one standard, you can start thinking it’s acceptable to keep deviating from it more and more, or start deviating from other standards. This can lead to…
  6. 6. 6 The “Deviation Spiral” Deviation 1 Deviation 2 Deviation 3 Deviation 4 Original Normal New Normal 2 New Normal 1 New Normal 3 No failureNo failureNo failure
  7. 7. 7 Challenger Space Shuttle Disaster, 1986  Engineers continually observed defects in the rocket booster O- Rings, but they became treated as an “acceptable risk”, due largely to schedule pressure, after repeated successful launches  Launch day was especially cold. Engineers initially issued an unprecedented “no-launch” recommendation, but were unable to persuade NASA to cancel the launch  One component suffered a failure of both primary and backup O- rings – led to disintegration of the booster rocket and then the shuttle itself
  8. 8. 8 And as if that wasn’t bad enough… NASA came to accept foam strikes on shuttle heat shields as “normalized deviance” as well
  9. 9. 9 Gulfstream Business Jet crash, 2014  Jet failed to achieve liftoff, went off the end of the runway  Gust Lock was engaged  “the pilots had neglected to perform complete flight control checks before 98% of their previous 175 takeoffs in the airplane… it is likely that they decided to skip the [flight control] check at some point in the past and that doing so had become their accepted practice.” – NTSB accident report  One source concluded the pilots likely had adopted a pattern of neglecting more and more checks over time. None of the standard checks had been performed prior to takeoff. Go to model
  10. 10. 10 Carbide Industries, 2011 • Manufacturing furnace explosion at Louisville, KY plant – fatalities resulted • US Chemical Safety Board incident report included an entire section on “Normalization of Deviance” as a cause • “…because Carbide did not thoroughly determine the root causes of the blows [over-pressure incidents that occurred in 1991 and 2004] and eliminate them, the occurrence became normalized in the day-to-day operations of the facility…CSB interviews verified that furnace blows were considered normal”
  11. 11. 11 Causes (of Normalization of Deviant Practices)  A belief that “rules are stupid and inefficient”.  Belief that work goals are best met by breaking rule(s)  Imperfect knowledge of standards  Fear of speaking up Source: The normalization of deviance in healthcare delivery. Banja, J. 2010
  12. 12. 12 What Can We Do About It? (Mullane) • Recognize your vulnerability -- “If it can happen to NASA, it can happen to anyone.” • “Plan the work and work the plan.” • Listen to people closest to the issue. • Archive and periodically review near-misses and disasters so the corporate “safety” memory never fades.