Video excerpt from the DVD Stopping Normalization of Deviance, which is available for purchase from the store.
In his program, “Countdown To Safety”, Astronaut Mullane delivers a powerful message on the individual’s role in keeping themselves and their teams safe in hazardous environments. Mullane introduces this subject with a recount of his own near-death experience in a fighter jet, when he failed to speak up about an unsafe situation. He assumed another crewmember, with more flying time, “knew best” about the safety of their operations. At a critical moment in a hazardous operation, Mullane surrendered his responsibility for safety to someone else and became a “safety passenger”. The result was his (and the pilot’s) narrow escape during their ejection from the crashing jet.
Mullane continues this thread: that each individual brings to their team a unique perspective on safety. Only when every person’s perspective is available for analysis can a team be truly safe.
Another significant message within Mullane’s “Countdown To Safety” program is his discussion on “Normalization of Deviance”. He uses the space shuttle Challenger disaster to define this term, its safety consequences, and how individuals and teams can defend themselves from the phenomenon.
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 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-contractor 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 with minor modifications to booster assembly procedures and that a grounding the fleet (required for a criticality 1 deviance) was not necessary. As flights continued safely the correctness of the decision to accept the deviance was reinforced. Slowly the team’s launch decision-making became infected with this logic: repeated success in accepting a “grounding” deviance implied future success.
Challenger was a “predictable surprise”.
After defining “Normalization of Deviance”, Astronaut Mullane continues with an explanation of how individuals and teams can defeat this dangerous phenomenon through these practices:
- Recognize one’s vulnerability to it; if it can happen to NASA it can happen to anybody.
- Plan the work and work the plan…under the umbrella of “situational awareness”.
- Listen to people closest to the issue.
- Archive and periodically review near-misses and disasters so the corporate “safety” memory never fades. (The loss of the space shuttle Columbia…17 years after Challenger…was a repeat of “Normalization of Deviance”. NASA’s safety memory had faded over those 17 years.)
The messages delivered in “Countdown To Safety” are reinforced with rarely seen NASA video and slides. The program is hard-hitting and fast-paced. It is certain to open the eyes of every viewer to their individual criticality to team safety.