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The Broken Gauge - Normalizing Deviance

By Eric Nickless/ACTS Coordinator Marathon Petroleum

One of the most damaging behaviors to any organization is also one of the hardest for an organization to deal with. It is called “normalized deviation”, a phrase coined by Dr. Diane Vaughan, a sociologist who wrote a book (The Challenger Launch Decision) about the failed launch of the space shuttle Challenger. Many of us remember exactly where we were when we heard of the Challenger explosion and its crew’s fate. The catastrophe was caused by the failure of an “O” ring gasket on the solid rocket booster. Because of severe organizational pressure and the threat of budget cuts, NASA allowed the launch to occur even with overwhelming evidence that this could happen at the “below normal launch temperatures”.

 The Normalization of Deviance is defined as: “The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization”, or in layman’s terms; It describes a situation in which an unacceptable practice has gone on for so long without a serious problem or disaster that this deviant practice actually becomes the accepted way of doing things, even to the point of training others to do the job in the deviant way. All organizations have it, but it is more likely to do catastrophic damage in certain industries. We would call it a short-cut, not following a procedure, or bending a rule. Seven years after Dr. Vaughan’s book was published about the Challenger disaster, it struck NASA again. The space shuttle Columbia disintegrated on return to our atmosphere due to a damaged heat shield. Shuttles returning with damaged heat shields had become the norm. Nothing had happened in the past, so the warnings from the front line were discounted. Nothing was done to make the tiles more adherent. But now, this missing heat shield tile was in a critical location. All they could do now was watch and hope, and deeply regret their inattention.

 Just in our lifetime the BP Deep Water Horizon catastrophe killed 11, the explosion at BP’s Galveston Bay Refinery killed 15, the Upper Big Branch Coal Mine disaster where 29 were killed and many other catastrophes can be held accountable to “normalization of deviance”. If it can happen in these industries, and at NASA, it can happen here, at your facility, on your unit, during your job, on your shift.

 Normalization of deviance can only be stopped by the individual. A simple example of this is walking through your unit and noticing a gauge that is broken. You take notice and think about changing it or reporting it to be changed. You get busy and forget to report it. You don’t travel that way for a day or so, then there you are again, looking at the broken gauge and you think “Oh, I forgot to report that gauge”.  By the next shift you work and travel that way; not you, nor anyone else has reported it, it’s not as big of a deal as it was before.  Over time you hardly notice it anymore. The broken gauge has become “normal”. It can be as simple as taking a procedural shortcut, not wearing your PPE, leaving a pallet in a work area, being late on a recommendation, not wearing your seatbelt, or a staff member that is late for a morning meeting. There are thousands of instances in every day, which once they start to become normalized are extremely hard to stop. We must each be personally vigilant and not allow ourselves, or others to go down this slippery slope. Once we deviate just a little, even though it seems innocent enough when it starts, is the beginning of a dangerous precedent. We must stop, step back and consider what the effects of taking a shortcut or bypassing a proceedure could be to us and others. We must have the courage to call out those that take shortcuts and explain the high risk of taking them. Accepting or tolerating them is not an option.

Make sure we deal with all the “broken gauges” in our daily routines, and we can protect ourselves from “normalization of deviance”, and possibly disaster.

Amazing Simple Ideas

Good day Tim,

On the life of Mine project at Sishen Mine where we are building infrastructure to increase the capacity of the mine.

The new big truck haulshop was completed structural with the sheeting to follow.

The contractor came on board with us and submitted the safety files for review and compliance.

After all permits were issued for construction the delivery started to arrive – long IBR sheets in bundles.

These bundles were unpacked for installation along the sides of the building. The long shapes these IBR sheets were awful to pick up and raise to an upright position to be fastened.

The shin protection were absent so a lot of contact were made to the edges causing abrasion sometimes small cuts.

During a safety coaching session an employee asked for hockey shin protectors to be tested.

These shin pads were very effective and it became a standard in their working instruction.

Employees still amazes me with simple ideas.

Give your workers the chance to express the concerns and support the meaningful ideas.

This project has achieved 500 consecutive incident free days today and is the pride of the Ramp-Up projects.




Marthinus Engelbrecht

Site Safety Superintendent



Yes Tim, it shows you what a simple - sometimes common sense - idea can do to improve safe working conditions. You sometimes need to think outside of the box.

By Pierre le Roux

The Numbers Trap

By Eric Nickless                                               Marathon Petroleum; Illinois Refining Division

Numbers are very important to every aspect of our lives. Everything in life is measured by numbers. Your address has numbers so you can receive your mail delivery and, find you in case of emergency. Numbers help us keep track of all sorts of things like ball game scores, bank accounts, test scores, shoe size, shoe price, groceries, height and weight; everything has a number attached to it. We check prices on vehicles and make sure they are competitively priced. We do the same with groceries, clothes, shoes, and electronics. Almost everything is attached to a number. We compare test scores to see where little Johnny or Jackie measure up, and where they have room for improvement so we can focus on that area and help them to succeed.

Our BBS process is no different; we collect data from good quality observations to see where we have problem behaviors, such as not wearing ear protection. Then we look at the reasons for the behavior. Are the ear plugs we supply uncomfortable? Are they not readily available? Is it a lack of training or is it just not “cool” to wear them. When we figure out the problem, we concentrate our efforts and recourses to solving the problem. Through proper training, expressing the importance of hearing conservation, making them more accessible or purchasing another type, we work toward solving the problem. If we identify something in need of repair or replacement, we move the resources to solve that problem also.  

If we get improper data, by chasing high numbers, we skew the very data that protects us! We may be looking at something else that is really not a problem at all, and not seeing the real problems.

Our whole world is competitive; we all strive to be the best, but high numbers may not always be the key to success. You may have the best time on the cross country course, but if you cut a corner along the way, you lose. All your hard efforts and preparation are wasted. I would rather only finish or place in the race and know it was a genuine effort, than to win knowing I had to cheat to do it. If you win the NASCAR race but are disqualified for suspension violations, all your money, time and efforts are wasted. Not to mention you have let your crew and fans down, and if you lose them, your sponsors will follow.

It is the same if we get caught in the numbers trap. We feel the competitive urge to pump out observations and begin to lose the quality of them. The conversations that take place are replaced by just writing them up or entering them on the computer without any real interaction. Or, worse yet, we “pencil whip” them to meet expectations.

Then we are left to chase false data, exposing ourselves and others to unidentified risks. We have met expectations, satisfied the drive for numbers, but then we have accidents and injuries. We lose our fans (good observers) and sponsors (employee ownership through management support) because they think the process does not work. If we are encouraging high numbers we are missing the concept and benefit that comes with a good observation.

If we as employees and owners of the observation process don’t participate, we are committing the same crime.  Let’s don’t get caught in the numbers trap. Instead we should focus on the one on one observation with personal conversation that has served us so well in the past. We should all participate by doing observations. Please look out for your fellow coworkers and yourself, and do a quality observation today!

Restructuring Challenges

We are running a pilot BBS programme on one of the crews in our Reduction department. I studied BBS as part of my Masters degree (majored in psychology) so was employed to implement various psyc based systems down here. I’ve started slowly because not many people understand what psychology is (they all think Freud). The BBS pilot was running very well until we had to do some restructuring, then the stress of that really reduced how many observations were being done (they were still being done but at a much reduced rate). Now we are working with the leaders to get the process back on track. The guys really respect it they have just fallen into the “I don’t have time to do it” trap. I’m currently working with the guys to try and understand why they think they don’t have time and how we can set things up so they clearly do have time. I have no doubt we will succeed. The people here are so dedicated to their work and to safety. I’m very lucky to work with such a great team.

Reinforcing a Yummy meal

I had a great experience yesterday.  Was in Anchorage and went to a diner for breakfast that was recommended.  The breakfast, good old eggs bennie, was perfect.  english muffin wasn't stale, egg cooked just write, all ever had a meal and for some just hit the spot?  Even the ham or whatever was thin and tasty....
So, I pulled out a ten dollar bill and called over the waitress.  I asked her, "Could you give this to the cook and tell him that my breakfast was the best damn breakfast I've had in months".  She smiled and said sure.  My objective wasn't the ten bucks, but the simple thank you for a great breakfast.   A few minutes later, in the back I heard "Holy shit, are you kidding me - how cool!".   The chef comes flying out and says "Did you give this me?"  I stated "Yes, you cooked my breakfast perfect and I'm appreciative".  He said "wow man, no one ever does this - thank you".  I said no problem and thank you!!!   I then watched as he paid it back personally for the next 10 minutes before I left.  HE PERSONALLY WAS BRINGING OUT EACH PATRONS breakfast.  He was jazzed - turned on.   It is so fun to have a moment where you recognize life is good...and others working their butts off might just find a better use for the next $10 in my wallet then whatever I'd waste it on.
Actively caring, kindness, does not need to be "random".   If intentional, a committed behavior daily, it's a ton more fun.   


Organizational Effectiveness

Using Covey's Advice

I have a few books from “Steven Covey” and I also met him in person back in the 90ths at a conference where he spoke about “7 habits of a highly effective people” which is a proven principle of fairness, integrity, honesty, and human dignity and helping people solve personal and professional problems to promote leaders. Below some ideas to be implemented in a production department;

·         Managers to seek out 5 different operators every day and thank them for working safely.  

·         Consider someone from the production areas to act as a safety advocate that can help spread the safety culture. 

·         Asking engineers in each area to volunteer to lead the stretching exercises on a daily basis with the teams.

·         Meet with the Flow line Managers of the area to identify the appropriate stretches and help get employee leading the stretches.  This will be added to the Operation 6 review as part of the safety efforts.

 Scott Burkins and Carmen Ramos, LENOX Industrial Products and Services, Newell Rubbermaid

Stopping STOP and going BBS

I am at the New Zealand Aluminum Smelter. 850 people work here. When I arrived here one year ago, the Du Pont STOP process was here and dying a slow death. It had become a nitpicking exercise. A 'gotcha' game.

I have successfully convinced the management team to let STOP go and have showed them the BBS way. I have been given the go ahead to pilot the BBS process in our Reduction department (thats where the alumina is turned into aluminum). The department health and safety reps have been asked if they would like to participate in the design of the process. Some have said yes and some have said no. Thats ok. So right now I am slowly but surely demonstrating to the guys that BBS isnt about catching people out and that they have so much to gain from it. I have started taking some of them through the incident data analysis process and its so cool to see how much they are learning and how passionate they are getting. I am looking forward to the roll out. Watch this space.

Donna Carter

Safety Advisor
New Zealand Aluminium Smelters Ltd,

Private Bag 90110, Invercargill
Tel:   + 64 (0) 3 218 5510

Actively Caring Dad

Tim, I thoroughly enjoyed your presentation on Wed. morning at the 2011BSN Conference in Reno, NV.  It was my first time attending the conference and look forward to attending it again in the future.

I have a very timely story I’d like to pass on to you.  On Friday afternoon, after the conference when I was at home, my daughter, age 8, asked if she could play outside.  I gave her the OK and she said that she’d like to use her skateboard.  I then went to work in the garage and, when I reappeared to check on her, she was about to start skating merrily down the street when I noticed she had put on her helmet, elbow pads, but just one knee pad.  The story of your son’s skateboarding adventures immediately flashed in front of me. 

What did I do?  I applied my new learning I received from you.  Instead of focusing on the missing one knee pad and instructing her that she needed to stop immediately, I simply located the missing pad and gave it to her.  I said, “This will help protect all of you.”  She stopped, put it on, and I thanked her for protecting herself from injury.

Keep up the good work.  Take care. 

Chris Hamilton - MS, REA

Senior Consultant

Loss Control Advisory Services

Liberty Mutual - San Ramon, CA 

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