Personal disasters – a long time in the making

How it all goes sideways, fast

By Doug Thomson

Anyone knowledgeable of the theories of safety management is probably quite familiar with the concept of the Normalization of Deviance, a concept defined by sociologist, Diane Vaughan, after the investigation into the tragic failure of the NASA Challenger Shuttle Mission.

Vaughan observed that in the lead up to the disaster there were a multitude of small decisions made that were thought to be within normal operating standards, but in reality were not.

Over time, what was thought to be normal at NASA had changed to the extent that a failure was almost guaranteed.

The unacceptable had become acceptable, and the process of changing had been remarkably logical, and when all of the little mistakes and modified norms lined up just right, the disaster was unstoppable.

Sometimes the result of this process is relatively innocuous – other times it explodes in horrific fashion like NASA’s Challenger Mission; the Bhopal, India, Union Carbide gas plant failure; the Chernobyl nuclear power plant meltdown; and the Ocean Ranger and Deepwater Horizon drilling platform disasters.

Each of these events, and thousands of others like them, is not the result of one fateful decision, but rather of a host of big and small decisions made over time. The uncomfortable reality is that we are all prone to these failures.

None of these failures is particular to any one industry, or for that matter is it restricted to industry at all. They occur in health care, every business, sports, government and in our private lives. But how do they work?

Take a lawn chair and park it on the sidewalk, near any stop sign one day, and count the number of drivers who:

• come to a full stop before the stop sign,

• stop a few feet past the stop sign,

• gently role through the stop sign, and who

• are nowhere near a full stop.

I’m pretty sure you know what you’ll observe.

Nobody starts his or her driving career ignoring stop signs. The stop sign and that stop line on the road are there to protect drivers and pedestrians.

But you know, it’s often hard to see the traffic from the stop line, I mean, really, the planners put the sign in the wrong place, right?

Wrong, and you know it.

Drivers (not all, but many) so often experience no harm at the stop sign that they gradually expand what is normal driving behaviour, because every successful partial stop or ‘roll through’ reinforces the bad behaviour until, for too many, the stop sign transmutes to a slow down sign.

I mean, come on, why stop, nobody’s coming?

What those drivers ignore is that as they expand their ‘deviation from the norm’ (getting further and further past the stop line) they also increase their risk of an accident.

Ignore the stop sign often enough and the likelihood of having an accident skyrockets.

What was abnormal has become normal and one more tiny error – like swatting at a wasp that flies into the car just as ‘you’ drive, too quickly, up to that corner where you don’t stop any more and everything goes sideways fast.

The disaster doesn’t have to be the Space Shuttle Challenger – it could be a child running across the street at the very moment you don’t stop, because you normalized deviance.

Your personal disaster is not the result of one terrible mistake – it is the result of a long series of events that have combined to lead you to where you are.