In his safety DVD, Stopping Normalization of Deviance, 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.
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 through these practices: recognizing one’s vulnerability to it; making it a religion to “plan the work and work the plan;” considering one’s instincts; and, archiving and periodically reviewing near-misses and disasters so the corporate memory never fades. (Mullane explains that the loss of the space shuttle Columbia–17 years after Challenger–was a repeat of Normalization of Deviance.) His instruction is supported with rarely seen NASA video and slides.
As are all of Astronaut Mullane’s safety videos, Stopping Normalization of Deviance is unique. It is on-target, fast-paced, visually captivating and, in places, very humorous.
Duration: 37 minutes (available in DVD only)