Accidents, Deviance, and Consequences — Normal Accident and Normalized Deviance Theories
Foundation
Catastrophic Risk Foundation
Within the USAF, like any other organization, decisions made in highly complex, tightly integrated environments may have unanticipated consequences.
Consequences of Poor Thinking
Poor Thinking Consequences
If Airmen are unaware of, or have failed to think through decisions, catastrophic failure can result.
Normal Accident Theory — Structural Perspective
Normal Accident Theory
The normal accident theory rests upon the assumption that in any highly complex high-risk organizational structure, decision failures are unavoidable.
High-Risk Systems
High-Risk Systems
High-risk systems are systems classified by:
- Complexity
- Coupling of multiple processes occurring in conjunction with one another
Vulnerable Systems
Vulnerable Systems
Systems that are interactively complex and tightly coupled are particularly vulnerable to catastrophic failure stemming from:
- Mistakes made by decision-makers
- Often small mistakes, which go unrecognized or uncorrected
Coupled System Effects
Coupled System Effects
In coupled (interdependent) systems, tight interactions based on poor decisions can magnify normal accidents into system-wide failure.
Linear vs Nonlinear
Linear vs Nonlinear
In simple linear processes, such as an assembly line, failure has a visible impact on the next process, but is identifiable and limited.
Nonlinear Cascade
When interactions are nonlinear and affect a variety of other systems, the failure of one component has unanticipated effects on many subsystems.
Tightly Coupled Cascade
Tightly Coupled Cascade
If the subsystems are tightly coupled (highly interdependent), a failure quickly causes:
- Changes in multiple systems nearly simultaneously
- Making it hard for leaders to diagnose the symptoms and determine the extent of the failure
Global Power Application
Global Power Application
Because Airmen project power globally, anticipation of the impact from even minor deviations from procedure or instruction is extremely challenging.
Normalized Deviance Theory — Behavioral Perspective
Normalized Deviance Theory
The normalized deviance theory is the gradual acceptance of unexpected events and risks as a normal behavior in the operating environment, including the acceptance of lower standards.
How Deviance Becomes Normalized
How Deviance Normalizes
This practice of producing shortcuts or variations to normal procedures eventually becomes normalized to the point where the deviance is no longer noticed.
Deviations as New Norms
Deviations Become Norms
Deviations become accepted as new norms and are no longer assessed using the habits of mind necessary to identify causes and find solutions.
Member Adaptation
Members Adapt
As organizational members become accustomed to the reoccurrence of seemingly minor but unpredicted anomalies, they become less concerned with the potential catastrophic effects of more severe failures of the same system.
Challenger Disaster Example
Challenger Example
A classic case of normalized deviance is the example of the Challenger space shuttle disaster.
O-Ring Erosion
O-Ring Erosion
In this case, the erosion of O-rings was NOT within acceptable tolerances. However, after its occurrence, several times with no catastrophic result, the members of the organization accepted their erosion as a normal and acceptable event, despite deviation from their engineering standards.
NASA Culture
NASA Culture
In this case National Aeronautics and Space Administration, as an organization, was working hard to make space flight feel routine.
Combined Factors
Combined Factors
The organization's culture, combined with:
- Cognitive bias
- External pressures
…led to the normalization of a potentially catastrophic failure.
Airman Application
Airman Application
Airmen must be aware of the type of organization they operate within and understand its complex interactions. We should:
- Guard against substandard procedures by continuously questioning the way we do business
- Consciously identify the "close-calls" and deviances from normal operations
- Ensure deviations from standards are analyzed as part of the decision-making process to gain an understanding of how to improve programs and implement new decisions