By Alan D. Quilley, CRSP
Astronaut Mike Mullane shared that experience with me when I had a chance to co-present with him recently. The project was to help get a large group of construction supervisors to focus on the safe construction of a large gas plant with more than 4,000 construction workers. No small project for anyone. Mullane is a fascinating individual and his presentation on teamwork is incredibly inspiring. I highly recommend that you take the opportunity to listen, read and/or watch him tell his stories about his rare experiences and his views of excellence in human effort. As Mullane tells us, when you are sitting on the top of a rocket on the launch pad, you want the team that built the rocket to be very good at working together.
Before this turns into a commercial for all things Mike Mullane I want to tell you how this rare individual changed the way I think about safety. The concepts of “normalized deviance” and “predictable surprises” belong to Mike’s explanation of the two space shuttle disasters. These tragedies can help give new meaning to what we humans are trying to do with our safety efforts. Let me try to explain how a unique astronaut changed how I think about safety.
You might remember that it was the “O” rings on the space shuttle Challenger rockets that caused a major malfunction which destroyed the shuttle and killed the crew. Most of us have seen the horrible video of the ship exploding. The story behind the disaster is unfortunately all too typical. It’s about normalization of deviance from what was known to be a significantly important standard. You see, the “O” Ring design and performance problems were well known to many at NASA. Not unlike many of our workplaces, over time, false feedback about risk situations is the outcome of us taking chances against our best knowledge and judgment. Using the wrong tool for a job, using an underrated crane to lift a load, operating a vehicle in need of repairs or just simply not wearing our personal protective equipment are all examples of deviations from what we know is correct.
Over time, if we take risks and get the false feedback that we can get away with the behaviour, we learn to believe that it’s okay to deviate from a standard.
To not wear our safety glasses is one example. Humans are wonderfully adaptable creatures and we are constantly learning from our experiences. Learning that we don’t actual go blind when we use a grinder without our eye protection is re-enforcing that taking this risk is a good idea. We can mistakenly learn that squinting and hoping we don’t get injured is working for us. We learn that not wearing eye protection is normal. Our feedback for such a risk is usually that we may save time (not having to get those darn safety specs) and we can be more comfortable (no one likes ill fitting safety glasses do they?).
Then one day, when we’re least expecting it, a metal shard hits our eye and we’re off to the hospital with a serious injury to an important part of our body. Then we start to justify the learned behaviour by telling stories of: “Doing this for 30 years without injury” and asking ourselves “How could it have happened?” We’ve normalized the deviance from what we all know by now is the right way to behave.
Those who knew about the “O” ring situation were not surprised by the disaster. In fact, some predicted the catastrophic failure not only on the fateful day but several previous launches. Each time they predicted that the failure would cause total loss of the vehicle and it didn’t happen then these very human folks did what humans tend to do. They were happy they were wrong. Over time this normalization of deviance made the predictable surprise inevitable.
You see my experience managing safety and investigating incidents makes the Shuttle Challenger set of circumstances all the more true as a story of predictable surprise.
There aren’t many situations that occur that result in a bad outcome that we can’t return to the past to see that we not only could we have predicted the outcome. In many cases we have predicted the outcome.
Case in point, if you drive your car at excessive speed for the road conditions it shouldn’t be a surprise that you find yourself in the ditch. If you’re honest with yourself there was probably a tiny voice inside you head telling you to slow down. An important message here is that we need to listen to those tiny voices. Your “gut” is making you uncomfortable about the situation. React to those feelings, those voices that are telling you to slow down.
The folks involved in the space shuttle disaster can tell us that there were many feelings and tiny voices warning them of this normalization of deviance. Some even communicated their concerns through reports and memorandums.
Don’t let the false feedback of “getting away from standards” lull you into a sense that it will be okay. Don’t let deviance from the norm become the new less than acceptable standard. Stay true to your instincts, if you believe we need to do certain activities to make our places of work safe then do them.
Don’t become complacent to the rigour of doing the job right. The last situation we need is to talk about predictable surprises that we could have prevented by staying on the course that we knew was the right one.
Thanks Mike Mullane for the lesson in safety!