Repeated Mistakes . . . Errors Made Over Time
NASA did it. Air Traffic Controllers do it. Fire fighters do it, and doctors, too. In fact, no one is immune from making rule deviations that can end in a bad way.
How bad? Really bad . . . like Chernobyl bad , or the space shuttles Challenger and Columbia bad, or Bhopal bad, and in any number of lesser-known catastrophes.
What happened in each of these instances were not simple mistakes or human error, but a series of perhaps small errors, shorts cuts or deviations from rules and standards. Each error may have been insignificant in of itself, but when combined with other errors or rule deviations, over time the results can be injurious or deadly.
Safety experts call these repeated mistakes or errors made over time, a normalization of deviance.
In fact, deviations (sometimes going under the name of errors, mistakes, or oversights) are common occurrences in most workplaces. These deviations are made without the intention of hurting anyone, usually under pressure or within time constraints. The person breaking the rules may even feel justified — they are saving time and money while getting the impossible done.
Many of these violations or shortcuts often result in no ill effects. The violations, shortcuts or deviations then continue. A normalization of deviance takes place. What should never happen, starts to happen on a routine basis.
At Chernobyl the emergency core cooling system was disabled and had everything went according to plan, it would have been no big deal. At Bhopal, many safety systems were not in working order, but management expected to find any leaks before something bad would happen. In the case of the space shuttle Challenger, NASA knew they had a critical seal problem for six years, but expected a solution or workaround before a dangerous or deadly situation developed. A lapse years later into that same approach resulted in the loss of Columbia.
In many situations, the normalization of deviance is subtle, even invisible to the people involved. It’s “how things get done” around here. Efficiency takes precedent over inspections or maintenance. Small equipment defects are let go, or standards are not met . . . on a regular basis. Operators start spending more time with their electronic devices than their instruments or gauges.
What happens next is no accident . . .
To be continued . . . .
Thank you for reading this . . .