Page 30 - OHS, October 2021

SAFETY CULTURE
The successful use of the lower standard over time is perceived as somehow an acceptable substitute for the original standard and, therefore, becomes the norm or the “new” standard for performance.
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management aligned systems which people helped greatly,
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making air travel safer than most other modes of transportation.
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two NASA space shuttle accidents involving the Challenger and the Columbia vehicles. The Challenger accident was the result of O-ring seal failure. It is interesting to note that four different vehicles flew 24 missions before the Challenger accident. NASA found indication of O-ring malfunctioning after every flight, with no significant consequences. As a result, the concern for these deviations and the potential for a disastrous outcome were basically ignored.
The Rogers Commission, set up to investigate this accident, found that NASA’s organizational culture and decision-making processes had been key contributing factors to the accident. NASA managers had known that contractor Morton Thiokol’s design of the solid rocket boosters contained a potentially catastrophic flaw in the O-rings since 1977 but failed to address it properly. They also disregarded warnings from engineers about the dangers posed by launching at the low temperatures of that morning and failed to adequately report these technical concerns to their superiors. Deviations from proper practice became normalized and accepted as the “new” operating practices. NASA had a major stand-down, implementing some changes to the vehicles as well as processes, practices and procedures going forward.
Seventeen years later, another normalization of deviation caused the loss of the Columbia space shuttle. During the launch of STS-107, its 28th mission, a piece of foam insulation broke off from the space shuttle external tank and struck the leading edge of the left wing. Most previous shuttle launches had seen minor damage from foam shedding with no serious consequence to the integrity of the vehicles. When the shuttle reentered the atmosphere of earth, the damage allowed hot atmospheric gases to penetrate and destroy the internal wing structure, which caused the spacecraft to become unstable and slowly break apart, killing all on board. After the disaster, space shuttle flight operations were suspended for more than two years, similar to the aftermath of the Challenger disaster.
Since the program ended, it is not clear if, after the second disaster, the safety culture at NASA had really changed or not. Safety cultures evolve gradually over time in response to local conditions, work pressures, the character of leadership and the
Deviating Standards of Performance
I attended a conference not long ago where Mike Mullane, a former astronaut, was the keynote speaker. Mullane spoke of leadership and performance standards. He used examples from his time in NASA, but his message is equally applicable to any industry, especially the construction industry. The point of his talk was the “normalization of deviance.” This concept was developed by Diane Vaughan in her exceptional study of the space shuttle Challenger accident. Mullane stressed the need to guard against the insidious effect of this concept.
Normalization of deviance is a phenomenon by which individuals, groups or organizations come to accept a lower standard of performance until that lower standard becomes the “norm” for them. This phenomenon usually occurs when individuals, groups or organizations are under pressure to meet schedule requirements, conform to budgetary considerations or deliver on a promise, while adhering to expected standards or prescribed procedures. Faced with a situation in which relaxing the standards or procedures gets the “job done,” they decide to utilize lower standards or less robust procedures with the expectation that when things get back to “normal,” they will go back to utilizing the higher standards or procedures.
Generally, the problem is resolved and, to their relief, with no adverse effect. However, the pressures do not seem to abate, and the lower standard may be used again. Every time this is done successfully, it becomes easier to do it the next time. The successful use of the lower standard over time is perceived as somehow an acceptable substitute for the original standard and, therefore, becomes the norm or the “new” standard for performance. As a result, the individual, group or organization stops seeing its action as deviant.
The NASA Example
A classic example of normalization of deviation involves the
26 Occupational Health & Safety | OCTOBER 2021
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