Expert Commentary

Normalization of Performance Deviations

Despite best efforts, many organizations suffer from performance deviation to some extent. This failure to meet expectations covers all aspects of performance, be it in production, efficiency, quality, profitability, customer service, safety, or any other goal or standard against which organizations may measure themselves.


Construction Safety
August 2014

Failures are usually due to systems or humans. Generally, in aviation prior to World War II, most accidents were attributable to mechanical (system) failure. During WWII manufacturing, technology and design improved such that more accidents became attributable to pilot (human) error than to mechanical failure. To counter this fact, human factors were incorporated into the design process, and standard operating procedures were developed for crews. This helped to some extent. The next watershed factor was the adaptation of crew/cockpit resource management in 1980, which helped further reduce accidents so much that flying is safer than most other modes of transportation today. This approach aligned systems and people to garner the best results.

Management Intervention and Worker's Role

Generally in industry, when a failure to perform (achieve a goal) occurs, an employee (worker) ends up on the receiving end of management intervention. This could go from a "friendly reminder" all the way to dismissal, depending on the seriousness of the failure or infraction. In the safety arena, the worker may also suffer physical harm resulting from some forms of performance failure.

For before-the-fact (incident occurrence) interventions, organizations develop programs, establish policies, present training, furnish information, post signage, provide supervision, conduct inspections, and offer feedback, rewards, and/or punishment to ensure management's expectations are met or to rectify failure to follow procedures. For after-the-fact (post-accident/incident) intervention, the organization investigates the resulting situation (accident) and generally makes one or two of the before-the-fact interventions a priority. This same approach is taken annually after studying loss data and identifying loss areas. The organization again makes one or more of the before-the-fact interventions a priority.

Deviating Standards of Performance

The solutions implemented usually have some effect (see the Hawthorne effect study), but unfortunately, the results are not highly effective and certainly not sustainable. The traditional findings usually point to some error or decision on the worker's part, which may have been compounded by some technical failure or management process. So, this begs the question as to why reasonably intelligent workers would do things that lead to unacceptable performance or accidents and injuries.

I attended a conference not long ago where Mike Mullane, a former astronaut, was the keynote speaker. He spoke of leadership and performance standards. He used examples from his time in the National Aeronautics and Space Administration (NASA) space program, but his message is equally applicable to any industry—especially the construction industry. The point of his talk was the "normalization of deviance." This concept was developed by Diane Vaughan in her exceptional study of the space shuttle Challenger accident. Mr. Mullane stressed the need to guard against the insidious effect of this.

Normalization of deviance is a phenomenon by which individuals, groups, or organizations come to accept a lower standard of performance until that lower standard becomes the "norm" for them. This phenomenon usually occurs when individuals, groups, or organizations are under pressure to meet schedule requirements, conform to budgetary considerations, or deliver on a promise, while adhering to expected standards or prescribed procedures. Faced with a situation in which relaxing the standards or procedures gets the "job done," they decide to utilize lower standards or less robust procedures with the expectation that when things get back to "normal," they will go back to utilizing the higher standards or procedures.

Generally, the problem is resolved and, to their relief, with no adverse effect. But the pressures do not seem to abate, and so the lower standard is used again. Every time this is done successfully, it becomes easier to do it the next time. The successful use of the lower standard over time is perceived as somehow an acceptable substitute for the original standard and therefore becomes the norm or the "new" standard for performance. As a result, the individual, group, or organization stops seeing its action as deviant.

The NASA Example

A classic example of normalization of deviation is the two NASA space shuttle accidents involving the Challenger and the Columbia vehicles. The Challenger accident was the result of O-ring seal failure. It is interesting to note that 4 different vehicles flew 24 missions before the Challenger accident. NASA found indication of O-ring malfunctioning after these flights, with no significant consequences. As a result, the concern for these deviations and the potential for a disastrous outcome were basically ignored.

The Rogers Commission, set up to investigate this accident, found that NASA's organizational culture and decision-making processes had been key contributing factors to the accident. NASA managers had known that contractor Morton Thiokol's design of the solid rocket boosters contained a potentially catastrophic flaw in the O-rings since 1977 but failed to address it properly. They also disregarded warnings from engineers about the dangers posed of launching at the low temperatures of that morning and failed to adequately report these technical concerns to their superiors. Deviations from proper practice became normalized and accepted as the "new" operating practices. NASA had a major stand-down, implementing some changes to the vehicles as well as processes, practices, and procedures.

Seventeen years later, another normalization of deviation caused the loss of the Columbia space shuttle. During the launch of STS-107, its 28th mission, a piece of foam insulation broke off from the space shuttle external tank and struck the left wing. Most previous shuttle launches had seen minor damage from foam shedding with no serious consequence to the integrity of the vehicles. When the shuttle reentered the atmosphere of earth, the damage allowed hot atmospheric gases to penetrate and destroy the internal wing structure, which caused the spacecraft to become unstable and slowly break apart, killing all on board. After the disaster, space shuttle flight operations were suspended for more than 2 years, similar to the aftermath of the Challenger disaster.

Since the program has ended, it is not clear if, after the second disaster, the safety culture at NASA had really changed or not. Safety cultures evolve gradually over time in response to local conditions, work pressures, the character of leadership, and the perception of the workforce. Acceptance of deviations from prescribed standards occurs gradually, affecting the culture in very subtle ways.

Turning to the Construction Industry

Production pressures are common in construction. And it is easy to see the normalization of deviance taking root. If a worker needs to use a stepladder to perform a task, but one long enough is not readily available, the worker is faced with a choice to take the time to find a longer one and possibly fail to meet the production goal or use the shorter one and get the job done. If the supervisor stresses production goals and the worker feels that his or her job might be in jeopardy, the logical choice will be to use the shorter ladder and meet the production goal.

If the worker chooses to bring up the lack of proper equipment being available for the task, the supervisor too is faced with a choice of accepting a delay or reduction in production while the appropriate equipment is secured or asking the worker to make do with what they have and get the job done. Underlying this decision is the knowledge that work has been successfully completed in the past with less than optimal equipment or procedures with little or no adverse effect.

So, in order to solve the immediate conundrum, the supervisor may ask the worker to proceed anyway but to be extra careful. The worker does so successfully. On the next day, they still don't have longer ladders, and the worker proceeds working on the top step of the shorter ladder. After a few days, the worker does not even think about the safety coordinator's admonitions. Working this way becomes accepted practice, and the deviation becomes normal practice.

The underlying result is that the worker no longer focuses on being extra careful as the work becomes routine. This increases the risk associated with the work. Most serious accidents are caused by small errors in judgment that are magnified through a cumulative sequence of decisions and actions by workers, supervisors, and other management personnel.

There are other effects as well. Other workers who witness this see a worker not following rules, and incurring no negative consequences. They also see the supervisor condoning breaking the rules. They now see working in this manner (unsafely) as accepted practice. More importantly, if they see the supervisor thanking the worker for completing the task in that manner, it institutionalizes unsafe work habits, thereby creating a culture of ignoring prescribed safe task execution and engaging in unsafe production practices. It is also important to note the fact that the proper equipment (ladder) was not available due to a failure on the part of supervision (management) to properly plan the work, so solving it by relaxing a safety rule also covers up the supervisor's error, thus fostering a more insidious deviance in supervisory performance standards.

The schedule is a powerful driver of production. When supervisors succeed in overcoming barriers through deviations from "good" work practices without adverse effects, they reinforce the use of performance discrepancies and deviant practices. After repeating this a few times, solving performance pressures by deviation becomes institutionalized, forming a culture of production, which leads to acceptance of deviations from good work practices. So, the reasons for a future failure become actually conforming to accepted deviant practice and the prevailing unsafe work culture rather than the violation of the original "good" performance standards.

Examples and Explanations

In work situations, a manager makes a wrong judgment call, a supervisor makes a miscalculation, or a worker takes a risk or ignores a safety rule, with no major consequence. Later, another situation arises that can be resolved with the same improper approach, and eventually it becomes easy to repeat the improper action because it seems to work and solves the immediate problem. That approach becomes the accepted way to deal with similar situations going forward. Not only is the deviation normalized, but it becomes the "new" normal and the accepted way to do things.

Following are a few examples of reasons why there are normal deviations from standard practices in organizations:

  1. At the operational level, safety rules may be perceived as hindering required production. Such rules are viewed as being inefficient or even counterproductive. As a result, workers and their supervisors find shortcuts or work-arounds to such rules to meet goals.
  2. Sufficient/appropriate information is not available. Workers may not know the organization's safety rules, or their importance may not have been made sufficiently clear. Workers will then continue to perform work at a level that seems acceptable to them based on their past experiences.
  3. The supervisor may not clarify or stress the need to follow safe work practices or not make a point of correcting unsafe work practices. Even worse, the supervisor may compliment a worker for achieving a goal using inappropriate procedures. This sends a message to the workforce that, as long as production goals are met, how they get accomplished is not relevant or important.
  4. When achieving production goals is stressed and safety rules ignored, workers come to believe that how they are going about doing their jobs is in fact in the organization's best interest. This justification of deviation reinforces the perception that safety rules are counterproductive and breaking them is actually good.
  5. Depending on the work climate or the perception of the workers of expectations and consequences, they may be afraid to speak up or point out barriers to performance, such as unreasonable expectations, insufficient time, deficient resources, or any other impediment to getting the job done. This leads to deviation from standards using inappropriate behavior. Repeated success increases the likelihood that rules will be violated and will eventually become normalized.

Changing the Culture

Reversing the normalization of deviance is difficult unless there is a structural change in the organization. This is not easy to do, as it is the culture that allows these deviations to occur and become accepted. According to James Reason, a poor safety culture has three overriding factors:

  1. Normalization of deviance is discussed at length above.
  2. Complacency results in accepting risk or underestimating the exposure of the act due to past experience. Complacency turns people into observers or passive participants rather than actively contributing stakeholders.
  3. Tolerance of inadequate systems has numerous fundamental cultural, leadership, and organizational causes, which will be addressed in a future article.

Conclusion

Organizations generally have an expected "conduct of operations." This is how they would ideally want to operate. This may involve meeting or beating the project schedule and/or budget, operating at a high level of efficiency, meeting or exceeding expectations, treating partners fairly, and operating ethically while being profitable. In short, "conduct of operations" represents a system of policies, practices, and procedures that ensure requirements are being met. Unfortunately, no organization is immune to the normalization of deviance, regardless of how robust its conduct of operations system may be. People erroneously come to believe that a minor departure from defined procedures is acceptable, when in fact they have started down the road that eventually will result in some sort of catastrophe.

A practical approach to combating this subversive phenomenon requires actively guarding against it. People, teams, and organizations must appreciate their vulnerability to this. There needs to be acute situational awareness. The climate has to make it safe for people to "speak up" and voice their concerns. There should be a forum where their insights are welcomed and even encouraged. They should receive feedback on their suggestions and participate in follow-up discussions.

Everyone diligently guarding against accepting lower standards in the organization requires a culture where doing the "right" thing every time—no exceptions—is the only way to do it. Management plays a critical role in the success of avoiding succumbing to this normalization of performance deviations.


Opinions expressed in Expert Commentary articles are those of the author and are not necessarily held by the author's employer or IRMI. Expert Commentary articles and other IRMI Online content do not purport to provide legal, accounting, or other professional advice or opinion. If such advice is needed, consult with your attorney, accountant, or other qualified adviser.

Like This Article?

IRMI Update

Dive into thought-provoking industry commentary every other week, including links to free articles from industry experts. Discover practical risk management tips, insight on important case law and be the first to receive important news regarding IRMI products and events.

Learn More



User ID: Subscriber Status:Free