This video contains a 30-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.
Astronaut Mullane’s comments are lavishly supported with rarely seen NASA videos and photos making it extremely 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, Astronaut Mike 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.
In the 24-missions preceding Challenger, there were multiple, serious instances of deviant performance in a critical component of the shuttle’s rocket boosters, but launches were never suspended to give engineers adequate time to address the problem. In hindsight, the serial justifications to continue launch operations, reveal an incremental creep from safety best practices, i.e., a normalizing process. Challenger proved to be a ‘predictable surprise’.
Mullane will derive these lessons from his Challenger discussion:
- A world class safety legacy does not imply you are safe in the moment. Past success can breed a dangerous complacency. NASA’s Apollo program represented the greatest safety legacy ever compiled, but it was no protection from the normalization of deviance that infected the NASA-Contractor shuttle team. Every job is new and all the risks that job contains are unchanged from yesterday.
- Risk has no memory. Risk is not diminished as a function of your success in repeatedly taking a risk. Humans have a difficult time believing that. We think a risk taken is a risk diminished. But the laws of physics involved in working in hazardous operations have no memory. Again, every job is new. Do it by the book every single time.
- There is never a ‘one-and-done’ when it comes to deviance from safety best practices. Just one successful safety short-cut can start a self-sustaining inertia of safety deviance.
- Report near misses. The discovery of a grave near miss on the second shuttle mission was not communicated to key safety personnel ultimately resulting in the fatal Challenger mission 4-years later.
- Leaders: Ensure your teams have the resources to safely achieve the assigned goals. NASA’s team was tasked to fly 24-shuttle missions per year. Post-Challenger analysis determined cost-cutting in the program only provided resources to safety fly approximately 8-missions per year. NASA’s drive to achieve the assigned goal resulted in safety short-cutting.
- Procedural compliance should be a religion. The procedures for work in all hazardous environments are figuratively written in blood. The lessons learned from past tragedy are incorporated into procedures to protect the worker from those same tragedies. Follow your documented procedures every time.
- Take each other’s back. At any given moment during hazardous operations, not everybody is bringing their A-game to work. Somebody can be seriously distracted by personal pressures…family, health, financial, relationships, etc. By watching out for each other we can save somebody from a serious injury/fatality.
- There is no rank or seniority when it comes to safety. This is particularly important to understand with the generational changes occurring in many workforces. Newly hired personnel working with older job veterans might believe ‘they don’t count’ in safety as much as the veteran at their side. We all count. See something, say something, do something. Do not assume others will ‘take care of it.’ You do it.
- Leaders: Make certain you empower your people, so they do ‘count’. In word and deed convey the message, ‘I want to see through your eyes. Do not assume I am aware of a problem or hazard or that somebody else will take care of it. Bring it to me.’