Stopping Normalization of Deviance: A Safety Program

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This DVD has been upgraded with more instructional detail. It has been lengthened from 37 minutes to 53 minutes and was filmed in high definition.

In his safety DVD, “Stopping Normalization of Deviance: A Safety Program,” Astronaut Mullane uses the space shuttle Challenger disaster to define this term, its safety consequences, and how individuals and teams can defend themselves from the phenomenon. (The terms “Normalization of Deviance” and “Predictable Surprise” are from Diane Vaughan’s book on the Challenger disaster, The Challenger Launch Decision.)

Challenger was the result of a failure of a booster rocket O-ring seal. Viewers will be shocked to know this failure was predicted: “It is my honest and very real fear that if we do not take immediate action to solve the problem with the field joint (the O-ring) having the number one priority, then we stand in jeopardy of losing a flight along with all the launch pad facilities.” (From a NASA memo dated six months prior to Challenger).

When a burn-damaged O-ring (a criticality 1 deviance) was first observed following the second shuttle mission, NASA, under enormous schedule pressure, convinced themselves the problem could be fixed without grounding the fleet (required for a criticality 1 deviance). When the next several missions flew without O-ring anomalies, the correctness of the decision to continue operations was reinforced. However, over the following several years, more cases of O-ring sealing problems were observed in the returned boosters but with each successful flight the false feedback that it was safe to continue flight operations was strengthened. In other words, the absence of something bad happening was being falsely interpreted as an indication that the team’s actions were safe when, in fact, it was mere random chance that a disaster hadn’t occurred. The team had gotten away with accepting a criticality 1 deviance so many times, the deviance had been normalized into the team’s decision-making process. Challenger was a “predictable surprise.”

After dramatically defining “Normalization of Deviance,” Astronaut Mullane continues with an explanation of how individuals and teams can defeat this dangerous phenomenon. His instruction is supported with rarely seen NASA video and slides.

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This DVD is copyrighted intellectual property. It cannot be duplicated, excerpted, broadcast or transmitted in any format, including internet transmissions, without the written permission of the author. It is intended solely for use by the company unit, division, office, organization or plant purchasing it. It cannot be shared among multiple company units without licensing from the author.

$650.00 USD. Postage included in purchase price. 1-3 days delivery for USA destinations. Two weeks+ for non-USA destinations depending upon customs delays in the destination country.
Duration: 53 minutes (available in DVD only)

$750.00 USD. Fed Ex Delivery. One to three days delivery for World destinations.
Duration: 53 minutes (available in DVD only)