24th Nov, 2021
On January 28, 1986, six astronauts and one schoolteacher boarded the Challenger space shuttle as millions of Americans watched the events unfold on live television. 72 seconds later, the spacecraft exploded midair leaving an entire nation stunned in its aftermath.
The Challenger disaster as it was soon dubbed by the press, garnered widespread attention almost immediately prompting a national level enquiry that featured the likes of the famed physicist Richard Feynman.
The blame was finally attributed to O-Rings used to seal joints in the solid rocket booster. But it was procedural lapses within NASA that ultimately took the spotlight.
Diane Vaughan, an American sociologist had a very interesting prognosis.
She believed that the disaster could primarily be attributed to NASA’s decision to fly the space shuttle despite a dangerous design flaw with the O-rings.
Vaughan describes this phenomenon as occurring when people within an organization become so insensitive to deviant practice that it no longer feels wrong.
As she puts it — “It’s the gradual process through which unacceptable practise or standards become acceptable.
As deviant behaviour is repeated without catastrophic results, it becomes the social norm for the organisation”
It’s called “The Normalization of Deviance”
Insensitivity occurs insidiously and sometimes over years because disaster does not happen until other critical factors line up. In clinical practice, failing to do time outs before procedures, shutting off alarms, and breaches of infection control are deviances from evidence-based practice.
As in other industries, health care workers do not make these choices intending to set into motion a cascade toward disaster and harm.
Deviation occurs because of barriers to using the correct process or drivers such as time, cost, and peer pressure.
As in other industries, operators will often adamantly defend their actions as necessary and justified but it often leads to disaster.
All deviance may not be bad, it may be important at times to change for the better but there is a thin line between deviance for improvement and deviance for short cut or compromise. Be wary of that.
Let’s check our own life for the flaws and deviant behaviour that is slowly creeping into our life and becoming the norm and may harm us.
Vaughn further states that the best solution for the normalisation of deviance is, ‘being clear about standards and rewarding whistle blowers. Also, create a culture that is team-based such that each person would feel like they were letting their colleagues down if they were to break the rules.”
A small leak can sink a big ship, be wary, take corrective action, don’t let deviance become the norm and Stay blessed forever.