Normalization of Deviance - article by CASA Flight Safety

Started by Live2Learn, May 15, 2017, 03:29:07 PM

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Live2Learn

This article applies to CAP.  http://www.flightsafetyaustralia.com/2017/05/safety-in-mind-normalisation-of-deviance/.  I'm sure most of us have observed this in CAP.  The truthful among us likely are guilty in one aspect or another.  This 'NoD' thing is a tough nut to crack.

James Shaw

I had a chance to read the article and found it to be a very true and direct story that highlights the mentality you may find in many organizations. I can relate to this primarily from the manufacturing side of the world. In my field we call this "safety creep" and is generally occurs over a long period of time by more than one person. However in my experience the "trigger" is usually narrowed down to the "first person" that allows this to happen. When the first one lets it slip in then the others involved may take it as an accepted practice. This would be especially true if the person is in a position of authority. This could be a first line supervisor or a member of the management team that "needs that machine to run". It is unfortunate that this happens. Part of the article had a quote in the middle that stated

'The fact that no negative consequence resulted from the inaction led to the deviance becoming normalized within the NASA culture"

This is very unfortunate but also a very realistic statement when there are no consequences. If this type of activity is allowed to continue to long and not be addressed then it takes a lot more work to get it out of the "cultural norms". I still see examples of this on occasion. It takes dedication and persistence to address it and you MUST have senior management's commitment to combat these actions.
I am very fortunate in that the team I have is made up of approximately 30 people with a mixture of front line supervisor to senior managers in the facility. We average 230 safety audits (monthly) as part of our Annual Action Plans. It is not a perfect system but it works very well. It is my Central Safety Committee that meets every month to discuss safety. As the Safety Manager I lead part of the meeting but we have different people leading various subjects.

One of the suggestions they have is "Appoint people with opposing views or ask everyone to voice their opinion before discussion". This is one of the most important statements in the article. A safety program does not need a bunch of "yes men/women" to make it easier to operate. I would further expand on this and suggest that it also needs to have a broad range of subject matter experts so that there is a challenge process to the discussion so that not everything is answered by a couple of people.

From the CAP perspective I can see that this could apply in many different areas. One that comes to mind directly is the Cadet program. For the past several years CAP has continued to tell squadrons and all of the Commander's that visitors such as perspective cadets CANNOT participate in the PT at the squadron until they are actual members and are covered by the CAP insurance. I am willing to bet that that this still happens more than we would like to think or admit. I do not feel that it would be intentionally done, but by an oversight of effort when the cadets are doing their activities. If a Commander at any level lets it knowingly happen then it automatically becomes an "accepted" and "approved" practice merely based off the Commanders perceived approval.

As to the suggestion to have people with "opposing views" involved I think everyone whether in CAP or civilian community needs more of this. I have seen safety managers, safety leaders, and other folks agree with everything the leader says simply because they don't want to disagree or be seen as a "complainer" or "trouble". From the safety perspective this is a nightmare that can and will ultimately lead to tragedy. Tragedy for the individuals who do not speak up, those that get rid of or drown out different opinions, and especially tragic for those impacted by a lack acceptance by others of someone who doesn't agree with them.

Something I do want to add to this that was not necessarily part of the article but I see as an extension of the NoD. The article did kind of talk about the "Top Down" approach. If the organization whether a private business, volunteer organization, or public agency does not prepare the employees for these roles, responsibilities, and expectations then they are damaging themselves. If they choose to limit the span of discussion and influence to a select few people within the organization, I believe it does just as much damage to the program. If you don't show value in the people and their knowledge, skills, or abilities then they will simply give up and stop trying to help.

This is also a double edged sword for the individuals involved. They must take it upon themselves to understand their areas to the point where they can challenge the "group think" intelligently so that people will take them seriously. I have Graduate and Undergraduate degrees in emergency management and safety and continue to learn from the hourly supervisors because they are the subject matter experts when it comes to their people, machines, and processes.

If all of your safety team agrees every time a safety topic comes up then you have the wrong people on your safety team. As an extension of that...If you feel that a Safety Officer should also be a pilot then you are limiting yourself to "group think".

Thanks for sharing.
Jim Shaw
USN: 1987-1992
GANG: 1996-1998
CAP:2000 - Current
USCGA:2018 - Current
SGAUS: 2017 - Current

husker

I use the Bedford crash case study often in ES training.   CAP is just as susceptible to these psychological/sociological issues as any organization.

http://www.rapp.org/archives/2015/12/normalization-of-deviance/

Michael Long, Lt Col CAP
Deputy Director, National Emergency Services Academy
nesa.cap.gov
mlong (at) nesa.cap.gov

James Shaw

Quote from: husker on May 17, 2017, 04:13:27 PM
I use the Bedford crash case study often in ES training.   CAP is just as susceptible to these psychological/sociological issues as any organization.

http://www.rapp.org/archives/2015/12/normalization-of-deviance/

Good article as well. I also agree that this type of behavior would likely be in just about any organization.
Jim Shaw
USN: 1987-1992
GANG: 1996-1998
CAP:2000 - Current
USCGA:2018 - Current
SGAUS: 2017 - Current

walter1975

These two articles are very important reading.  As an observer with some 400 hours between CAP, Coast Guard Auxiliary, Air Force aircrew on E-3s, and Navy E-2s, I am a firm believer that all crew members have an interest in getting home safely, and that interest = responsibility + action.  In my experience that means (1) a trained crew, (2) communicating as a team, (3) using cockpit resource management, and (4) following the checklist for routine actions.  Everyone has to be able to say (1) this scares me, (2) this isn't right, (3) we are not following procedure, (4) we aren't on the checklist, (5) I don't understand this, and the biggie (6) you are impaired - and everyone else has to listen and honor the call.  And exactly the same items apply in any form of emergency response work - whether you are operating in an emergency operations center or as a single resource in the field.

If you think about it, if you apply the same principle to ground operations or to regular management of unit activities, the principle applies.  When we do so, as an aviation organization, we are creating a culture that fosters safety and effective action and good management.     
SM Walter G. Green III, CAP
Finance Officer
Group 4, Virginia Wing

Live2Learn

Quote from: husker on May 17, 2017, 04:13:27 PM
I use the Bedford crash case study often in ES training.   CAP is just as susceptible to these psychological/sociological issues as any organization.

http://www.rapp.org/archives/2015/12/normalization-of-deviance/

Thanks for the reminder.  I recall both the accident report (it's awful) and the short lived introspective articles it generated.  So, how do we realistically get beyond the human factors, defensive behaviors, etc. that conspire to ignore or create real social barriers to daylighting systemic issues that fall under the heading of 'NoD'?   That, in itself would be an interesting conversation/class at NESA and elsewhere.