Please visit Mike’s YouTube channel to see excerpts from his speaking programs and from his safety video.
This English-language video contains a 35-minute discussion on the dangers of normalizing deviances from safety best practices and how to protect yourself and team from falling victim to this normalizing phenomenon.
It also contains a 13-minute discussion on individual responsibility and accountability in hazardous environments.
Mullane’s comments are lavishly supported with rarely seen NASA videos and photos making it very easy for any audience (including non-technical audiences) to follow and understand the message. You do not need to be a rocket scientist to be thoroughly educated, inspired and motivated by the contents of this video!
Normalization of Deviance
In this discussion, Mullane uses the Space Shuttle Challenger disaster as an example of how a World-class team can be victimized by incremental deviances from safety best practices.
Challenger was a result of a catastrophic failure of the O-rings, Criticality 1 components used to form pressure seals between the four propellant-filled segments that comprise the twin solid fueled rocket boosters. Even though there were multiple instances of leaking O-rings in the 24 missions preceding Challenger, launches were never suspended to give engineers adequate time to address the problem. In hindsight, the serial justifications over a 4 year period to continue launch operations, reveal an incremental creep from best practices, i.e., a normalizing process. Challenger proved to be a ‘predictable surprise’. Mullane will discuss the following factors contributing to the ultimate tragedy:
- Extreme launch schedule pressures.
- Conflicting performance results with the O-ring seals.
- A developing sense of ‘margin’ in the performance of the O-rings.
- A significant communication breakdown which kept the grave concerns of the contractor engineers from key decision makers.
From this discussion, the following lessons are derived:
- Normalization of deviance is rooted in decision-making while under job-related or personal pressures. Everybody is vulnerable. Procedural compliance will always be the best defense. Make it a religion.
- Maintain situational awareness. Have a questioning attitude.
- Risk has no memory. Risk is not diminished by the frequency at which one is successful in taking the risk.
- Beware of this thought process, ‘These are exceptional circumstances. I must take the short-cut. Next time I will do it right.’ One successful safety short cut provides this false feedback: The absence of a negative consequence suggests a risk previously believed to be absolute is, in fact, manageable. One short-cut opens to door to more.
- Set challenging but attainable goals. NASA’s shuttle launch goal of 24 missions per year proved to be unattainable and pressures that resulted from that goal were significant factors in the tragedy.
Responsibility & Accountability
Mullane will introduce this 13-minute discussion with a personal story from his USAF flying career. At the time of the story, Mullane was a very experienced Weapons System Operator from the backseat of the reconnaissance version of the
F-4 Phantom jet fighter but making his first flight in a swing-wing, supersonic F-111 jet. Ultimately, he and the pilot had to make a last second ejection from the crashing jet. This crash was due to crew error…including Mullane’s failure to speak up at a critical moment in the flight. From this story he will develop these lessons:
- See something, Say something. Do something.
- We’re all in it together. In hazardous operations, the actions/inactions of a single individual can endanger everybody. Take each other’s back.
- One person with courage forms a majority. You count. You are unique. You might see something safety-related that nobody else sees. Never be a ‘safety passenger’ and assume somebody else will ‘take care of it.’
- Leaders: Empower your teams so everybody does count.
- We all contribute to the safety culture of a team and will be accountable for our contribution. In hazardous operations, you may not get a ‘do-over’. OWN your safety responsibility.
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