Normalisation of deviance

Summary

This webinar, hosted by Trish Caron, Director of the IME Safety Center, delves into the concept of 'normalization of deviance', a phenomenon where warning signs are ignored due to complacency. Using the Columbia space shuttle disaster as a case study, the presentation explores how repeated deviations from safety protocols can become normalized, leading to catastrophic outcomes. It also examines historical incidents across various industries to highlight the dangers of this phenomenon and emphasizes the importance of recognizing and addressing deviance to prevent future tragedies.

Takeaways

• 🚀 The concept of 'normalization of deviance' was introduced by sociologist Diane Vaughan, highlighting the dangers of ignoring warning signs due to complacency or false assumptions of safety.
• 🔍 The Columbia Space Shuttle disaster serves as a case study for normalization of deviance, where foam insulation damage during launch was initially a concern but later became an accepted risk, leading to catastrophic failure.
• 📈 NASA's history of debris strikes on shuttles shows a pattern of increasing acceptance of risk, with incidents like the Atlantis shuttle's near burn-through event and the Columbia disaster illustrating the dangers of complacency.
• 🛠️ The Challenger disaster in 1986 also exemplifies normalization of deviance, where known design flaws in the O-rings were deemed acceptable risks, leading to the explosion and loss of the crew.
• 🔥 The BP Texas City refinery explosion and the Deepwater Horizon disaster both demonstrate how deviations from standard procedures and confirmation bias can lead to major accidents.
• 🌋 The Pike River coal mine disaster in New Zealand shows how normalization of high methane levels led to a fatal explosion, despite clear warning signs being ignored.
• 🛳️ The Costa Concordia cruise ship disaster highlights how routine deviations from safety protocols, such as performing salutes too close to shore, can become normalized and lead to tragedy.
• 🔍 The importance of monitoring and maintaining safety instruments was emphasized, as failed or ignored instruments can lead to critical information being overlooked, as seen in the Columbia disaster.
• 🤔 The webinar discusses the need for organizations to focus on proving systems and actions are safe, rather than assuming they are safe until proven otherwise, to prevent complacency and normalization of deviance.
• 📊 The discussion on measuring safety performance by the absence of incidents can embed normalization of deviance, as the lack of reported incidents is not necessarily evidence of a safe workplace, but could indicate ignored warning signs.

Q & A

What is the main topic of the IME Safety Center webinar presented by Trish Caron?

The main topic of the webinar is the concept of 'normalization of deviance,' which refers to the phenomenon where warning signs are ignored or become unnoticed over time, leading to potential safety risks.

Who introduced the term 'normalization of deviance' and in what context?

Sociologist Diane Warren introduced the term 'normalization of deviance' in her 1996 book 'The Challenger Launch Decision,' which was about the Challenger space shuttle disaster.

What is the significance of the Columbia space shuttle case study in the webinar?

The Columbia space shuttle case study is used to highlight the factors around normalization of deviance, as it is a well-documented incident where such behavior led to the tragic loss of the shuttle and its crew.

What was the role of foam insulation in the Columbia space shuttle disaster?

The foam insulation from the external tank broke away during launch and struck the left wing of the orbiter, damaging the thermal protection system, which ultimately led to the shuttle's disintegration upon re-entry.

How did NASA's response to debris strikes evolve over time, as illustrated by the case studies?

Initially, debris strikes were considered a safety of flight issue, but over time they became an accepted risk and were normalized within the organization, leading to a shift in focus from addressing the issue to merely analyzing the probability of damage.

What was the initial design specification for the Space Shuttle program and how did it differ from the reality?

The initial design specification for the Space Shuttle was to provide routine access to space with around 50 flights per year. However, by 1989, it was only conducting 24 flights a year due to budget overruns and capability issues.

What cultural factors within NASA contributed to the normalization of deviance?

Cultural factors included a hubris associated with past successes, a rejection of criticism and externally imposed changes, and a focus on proving systems and actions were safe rather than proving they were unsafe.

How did the Challenger and Columbia investigations reveal similar cultural issues within NASA?

Both investigations found a failure to learn from past incidents, inadequate concerns over deviation from expected performance, and a silent safety program within the human spaceflight area of NASA.

What is the importance of leading versus lagging safety performance metrics in identifying normalization of deviance?

Leading metrics focus on proactive measures and can help identify potential issues before they become normalized, whereas lagging metrics like incident counts can embed normalization of deviance by focusing on the absence of incidents as a measure of safety.

What are some strategies organizations can use to prevent the normalization of deviance, as suggested by the webinar?

Strategies include multi-tiered risk assessments, sign-off by competent technical authorities, rewarding the identification of deficiencies, and focusing on leading safety performance metrics.

How can the concept of confirmation bias contribute to the normalization of deviance?

Confirmation bias can lead individuals to seek out and interpret information in a way that confirms their pre-existing beliefs, potentially normalizing deviance by overlooking or dismissing warning signs that contradict the belief in a safe and successful operation.