CHRIS ACORD
Workplace Safety Division
Directorate of Analysis and Prevention
U.S. Army Combat Readiness Center
Fort Rucker, Alabama

The old adage, "familiarity breeds contempt," rings eerily true when considering the dangers of normalizing deviance. Coined by sociologist Diane Vaughan, this phenomenon describes the gradual process where individuals, groups or organizations tolerate unacceptable behaviors, practices or conditions as normal. Like a thief in the night, normalization of deviance creeps in silently and dulls the sense of wrongdoing. Normalizing deviance often masquerades as efficiency, cost-cutting or simply “the way things are done around here." But this insidious drift toward accepting substandard practices as the new normal can have catastrophic consequences, particularly in high-risk industries like aerospace, healthcare and the military.

The Dangers of Accepted Deviance

The true danger of normalizing deviance lies in its subtlety. Initially, deviations might seem minor and inconsequential. Examples include skipping a procedural step due to a time crunch, deferring a minor maintenance procedure because "it's never caused a problem before" or bending the rules on driver training due to competing priorities. These seemingly insignificant acts, when repeated and uncorrected, erode safety margins and pave the way for disaster.

The longer these deviations go unchallenged, the more ingrained they become in the organizational culture, making them even harder to eradicate. Dr. Robert Figlock of Advanced Survey Design, LLC, aptly warned senior military leaders in 2005, “When cutting corners becomes routine, and routine violations become the norm, then they may not be seen as violations at all to a newcomer who perceives, ‘That’s the way it’s always been done around here.’ The practice becomes the rule, rather than the exception to the rule. Over time, the correct rule is lost. With so much on-the-job training (OJT) conducted in the fleet to train new personnel, routinely cutting corners is a setup for future calamity.” In other words, as deviations become ingrained in organizational culture, they become harder to eradicate, lulling teams into a false sense of security and increasing the likelihood of sending a chaplain and a casualty notification officer to visit the next of kin.

Organizational Culture: The Breeding Ground

Organizational culture plays a crucial role in either fostering or preventing the normalization of deviance. A culture that tolerates shortcuts, prioritizes production or time over adhering to safety procedures, or discourages open communication about risks creates fertile ground for deviance to take root. For example, factors such as:

• Production pressure or OPTEMPO: When ineffective planning and time management create unrealistic deadlines and performance goals that incentivize cutting corners.
• Overconfidence in experience: Highly skilled or experienced personnel may believe their expertise allows them to bend rules safely, leading to increased risk-taking.
• Allowing unwritten practices to become standard: When deviations go unaddressed by supervisory personnel, it sends a message that they are acceptable, which causes individuals to continue deviating without fear of repercussions.
• Rationalization of behavior: Once established, deviance becomes the accepted norm, making it harder for individuals to recognize and challenge unsafe practices. People justify deviations by thinking, “We’ve always done it this way,” or, “Nothing bad has happened before,” dismissing potential dangers.
• Absence of catastrophic failure: Organizations often respond only after a major failure or disaster occurs. In the absence of such an event, deviations continue unchecked.
• Stifling communication: A culture where individuals feel uncomfortable reporting safety concerns or challenging unsafe practices allows deviance to flourish.

Case Studies: When Deviance Turns Deadly

History is replete with examples of mishaps where normalized deviance played a significant role, including:

• Challenger Space Shuttle Disaster (1986): Engineers had expressed concerns about the O-rings' performance in cold temperatures, but these concerns were overruled due to launch schedule pressures and a history of seemingly successful launches despite O-ring erosion. This normalization of the known risk ultimately led to the tragic loss of the shuttle and its crew. (Astronaut Mike Mullane - Normalization of deviance - IAFF - Part 1 at: https://www.youtube.com/watch?v=Ljzj9Msli5o)
• Columbia Space Shuttle Disaster (2003): Foam shedding from the external tank during launch had become a normalized occurrence, despite its potential to damage the shuttle's thermal protection system. This acceptance of a known risk ultimately led to the disintegration of Columbia upon re-entry over the southern states.
• BP Texas City Refinery Explosion (2005): Cost-cutting measures and a lax safety culture contributed to numerous safety violations becoming normalized, culminating in a catastrophic explosion that killed 15 workers and injured 180. (BP Texas City 10-Year Anniversary Safety Message: https://www.youtube.com/watch?v=hcKM4xWywLE)

The U.S. Army, like the organizations in the above-listed case studies, is not immune to cultural factors that cause mishaps. To proactively address this, the U.S. Army Combat Readiness Center developed the interactive "Dirty Dozen" poster series (https://safety.army.mil/MEDIA/Safety-Brief-Tools), identifying the 12 most cited mishap causes from fiscal years 2020-2024. This resource empowers commanders to analyze their units' specific risks, understand their potential impact and develop targeted strategies to prevent dangerous practices from taking root.

Combating Normalization of Deviance: Best Practices

Organizational leaders play a vital role in preventing normalization of deviance. Key initiatives include:

• Cultivating a strong safety culture: This is the cornerstone of a resilient and responsible organization, built on a foundation of trust and shared values. These, in turn, are essential for prioritizing the well-being of its people and the sustainability of its operations.
• Encouraging open communication: Create a reporting culture where individuals feel comfortable raising safety concerns without fear of reprisal. Anonymous reporting mechanisms may be used to promote a level of comfort.
• Enforcing accountability: Address deviations promptly and consistently, regardless of their perceived severity. This demonstrates that safety rules are not negotiable.
• Promoting continuous learning: Don't let complacency set in. Regularly review procedures, conduct safety audits, review near-miss incidents to identify potential areas of concern, and encourage employees to identify potential hazards and suggest improvements.
• Leading by example: Leaders must demonstrate their commitment to safety through their actions and decisions. They must be willing to challenge unsafe practices, even if it means delaying production.
• Just culture: Implementing a just culture model helps create a learning environment where individuals feel safe reporting errors and near misses without fear of blame, fostering continuous improvement and preventing the normalization of deviance.
• Reward adherence: Recognize and reward individuals and teams that consistently prioritize safety and ethical behavior.

By understanding the mechanics of normalization of deviance and proactively implementing preventive measures, organizations can create a culture of safety and responsibility, protecting the Army’s most valuable asset — its people.

References

• Vaughan, D. (1996). The Challenger launch decision: Risky technology, culture, and deviance at NASA. University of Chicago Press.
• Reason, J. (1990). Human error. Cambridge University Press.
• Hopkins, A. (2000). Managing human error in operations. CCH Australia Limited.
• United States. Chemical Safety and Hazard Investigation Board. (2007). Investigation report: Refinery explosion and fire. Report No. 2005-04-I-TX. Office of Investigations and Safety Programs, U.S. Chemical Safety and Hazard Investigation Board.
• Presidential Commission on the Space Shuttle Challenger Accident. (1986). Report of the presidential commission on the space shuttle Challenger accident.
• Columbia Accident Investigation Board. (2003). Report of the Columbia Accident Investigation Board.