Normalization of Deviance –Impacting Your business
The Royal Air Force (RAF) of the UK recently reported on an inflight incident that could have resulted in the loss of an airplane and the deaths of almost 200 people on board. Luckily, it did not. The incident was caused because the pilot, after using his personal SLR camera to take photos of the cockpit, placed the camera between his armrest and the side-stick controller (The airplane was an Airbus tanker, and all new Airbus airplanes use a “joystick” located beside the pilot rather than a more traditional stick or control wheel located between the pilot’s legs). When the pilot adjusted his seat, the camera became wedged against the side-stick controller and caused a sharp nose-down pitch. Fortunately, a fatal accident was prevented by the built-in safety systems of the Airbus airplane, but only after twenty-four passengers, all seven cabin crew, and the copilot (who was taking a short break) were slammed against the passenger compartment ceiling.
The subsequent investigation identified the proximate cause but observed that the basic problem was a normalization of deviance from standard procedures. This is an important observation and one worth exploring.
“Normalization of Deviance” is the term applied to the tendency of human beings to incrementally accept behavior that is abnormal, unacceptable or dangerous. Two classic, and tragic, cases of the normalization of deviance are the losses of the Challenger and Columbia space shuttles. In both cases, abnormal events (for Challenger, the erosion of the “O” ring seals between solid-rocket-motor booster sections and for Columbia, the shedding of foam insulation from the external fuel tank at launch) were initially viewed with great alarm. However, as additional experience was accumulated without any significant accidents or incidents, the erosion of the “O” ring seals and the shedding of insulation were viewed with increasingly less and less alarm until it became “normal.” Normal until people died.
NASA and the RAF are certainly not the only organizations to succumb to “normalization of deviance.” Any time a safety procedure or an organizational policy is violated and the violation is left uncorrected, the organization is opening itself up to increasing numbers and significance of such violations. Whether the procedure is a requirement for two-person operation of machinery, routine changing of passwords, conduct of annual background checks or wearing of identification badges, acceptance of minor deviations from the procedure can easily become routine, and such routine violations increase the probability of a disruptive event. It’s important to recognize that the probability of a disruptive event is a function of time and that the cumulative probability continues to increase as long as the deviation is not corrected. That is what happened to both Challenger and Columbia – eventually the cumulative probability caught up with NASA.
Recognition of human behavior and the tendency to accommodate “normalization of deviance” is essential when developing business continuity programs and plans. Mitigating this normalization of deviance requires:
- Procedures that are actionable and designed to achieve the intended result. Overly-stringent procedures (changing computer passwords every four hours) can create a perverse incentive to violate the procedure leading to the slippery slope of normalization of deviance, so it’s important to design the procedures properly.
- Procedures that are enforceable with minimal burden on people. As with overly onerous procedures, overly onerous enforcement incentivizes deviance. Regular refresher training and regular exercises are two good ways to enforce procedures – but not the only ways. Due consideration must be given to how procedures will be enforced when those procedures are being developed.
Business continuity requires the understanding and mitigation of human behaviors when those behaviors are counterproductive. It requires the prediction of likely problem areas, planning to mitigate those problems and then performing when necessary. PREDICT.PLAN.PERFORM.®