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.

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