LISH FD Training Blog

By Lance C. Peeples
From www.fireengineering.com

I recently had the opportunity to view a YouTube video of Astronaut Mike Mullane discussing the "normalization of deviance." In his talk, Colonel Mullane describes how the Space Shuttle program came to accept the damaged "o" rings that ultimately led to the catastrophic failure of the Challenger during its last lift off from Kennedy Space Center. According to Mullane, in 14 of 24 previous flights, inspection revealed slightly damaged "o" rings that had been exposed to the effects of significant heat…this despite the fact that these "o" rings were engineered NEVER to be impinged upon by fire. Engineers identified this as an "urgent" design flaw; six months prior to the catastrophe, one engineer even called for "immediate" reengineering of the "o" rings. Unfortunately, the original standard (i.e. no damage/flame impingement) that had been developed when there was no pressure was rejected by the space program leadership when there was tremendous pressure to keep the shuttle flying. To justify this position, NASA tested in the laboratory damaged "o" rings, which did not fail during the testing. The fact that there was no bad experience reinforced the acceptance of the lower standard. The difference between the original and new (lower) standard was never recognized! The difference (deviance) between the two standards had been accepted (normalized)…indeed, according to Astronaut Mullane, the team had come to EXPECT some "o" ring damage in their postflight inspections despite the original design specification that there should NEVER be any damage.
NASA's "normalization of deviance" prior to the Challenger disaster demonstrates a natural human tendency to take shortcuts, i.e. deviate from standards when the pressure is on. It's easy to say we won't tolerate "o" ring damage when there is no pressure, but much harder when millions of dollars are at stake!

This normalization of deviance is not just a problem for the space program--it is also a threat to firefighters. It is easy to take shortcuts. Imagine these scenarios:

• "I'm not going to wear my self-contained breathing apparatus (SCBA). it's just an automatic alarm."
• "I'm not stretching the 1 ¾-inch line, it's just a car fire."
• "I'm not taking the can, it's nothing."

The problem with deviating from the original standards is that almost always nothing bad happens! There is no fire, the car fire goes out, and we don't need the water extinguisher. The fact that there are no repercussions reinforces the deviant behavior until the deviant behavior is accepted as the new norm. Now we NEVER wear our SCBA unless there is evidence of a job, we ALWAYS use a booster on a car fire, and we NEVER carry the can. We rationalize that in our experience nothing bad has happened and therefore the new, lower standard is acceptable.
We may even continue to accept the new lower standard in the face of overwhelming evidence to the contrary. Many firefighters don't take automatic alarms seriously despite the tragic deaths of two Memphis (TN) firefighters at an alarm investigation several years ago. Firefighters still use 1 ¾-inch inch lines with automatic nozzles off standpipe systems despite the fact that these systems were in many cases engineered to be used with 2 ½-inch lines and solid bore nozzles. These firefighters have not personally experienced the cost of not adhering to these old standards and relying only upon the evidence that these new lower (unrecognized deviance) standards have not failed in their limited experience continue these types of dangerous practices until a tragic failure occurs.

(1) Normalization of deviance can lead to a groupthink mentality where new, lower standards are accepted despite evidence that these standards are dangerous.
Preventing Normalization of Deviance
Having identified the natural human tendency to accept shortcuts and rationalize those shortcuts under pressure and that the lack of bad consequences often reinforces the "rightness" of these shortcuts, what can firefighters do to ensure that they are not blindsided by this? Colonel Mullane offers several suggestions:

1. Recognize our vulnerability to accept shortcuts under pressure.
2. Execute to meet standards.
3. Trust your instincts.
4. Archive and review

Let's discuss each of these suggestions in the context of the fire service.

1. Recognize our vulnerability to accept shortcuts under pressure. Possibly the easiest way to avoid shortcuts on the fire scene is to decrease the pressure. How do we do that? Constant training until our operations become reflexive. Repeat drills until we develop "muscle memory" that decreases the time constraints, i.e. pressure that leads us to take unsafe shortcuts. We don't think about which standpipe hose to use--we always drill with the 2 ½-inch line on the standpipe. We don't have to think whether the 28-foot extension ladder will reach--we KNOW because we have repeatedly drilled with it. We know our still district like the back of our hand so we don't deviate from the standard that requires we drive at a safe speed. We don't take shortcuts because we have drilled repeatedly on the initial high standard until we do it reflexively and have to consciously think about deviating from that standard because of some unusual circumstances that demands a change of plan. The pressure to accept shortcuts and the normalization of deviation can be reduced via constant, never-ending, and realistic training!

2. Execute to meet standards. Standards are developed over time to meet a defined condition or threat. Even in the absence of pressure, there is the temptation to take shortcuts. This failure to execute can usually be ascribed to one of three things:
A. We don't know what the standard is. Here the solution is education. Fire officers and firefighters must understand the "why" as well as the "how" of a given operation. If a firefighter does not understand the hydraulic constraints of older standpipe systems, he will not understand why it is important to use 2 ½-inch hose with a solid bore nozzle when operating off a standpipe.
B. We know what the standard is but we are unable to perform it. If this is the problem, we must either train to correct the deficiency or develop some engineering control that assists us in meeting the standard. For example, if the firefighter is not strong enough to operate the 2 ½-inch line, we may need to develop a physical conditioning training program.
C. Finally, we know what the standard is but we refuse to adhere to it. In this system, we are not motivated. A system of either rewards or punishments may be required to get us to adhere to the standard. Here, if we educate and train the firefighter on why 2 ½-inch hose is required for standpipe operations and he still refuses to use it, then it may be necessary to discipline the employee.

3. Trust your instincts. Instincts are developed via a combination of education, training, and, most importantly, experience (provided that experience is the "correct" experience). If our only experience is "incorrect" then what we really have is "tenure" and not "experience." We can (and must) make sure that our "experience" is "correct" by cross-checking it against other people's experiences in similar circumstances. This is the process of education. "Correct" experience, education, and training will allow us to develop instincts that help to protect against the development of groupthink and deviation from accepted norms or standards. Of the three strategies for resisting the "normalization of deviance," this is perhaps the most difficult, for it often times requires extraordinary courage to defend a standard against our peers or superiors.

The "normalization of deviance" is a dangerous phenomenon in which new and lower standards are substituted for older and stricter standards based on recurrent "experience" where shortcuts did not result in bad consequences. Ultimately, the inadequate standard replaces the old "correct" standard and becomes the new norm. The new standard may result in future disaster when it proves inadequate to prevent previously known hazards. Firefighters must guard against the development of deviancy by constant education and training.