Normalization of Deviance: The Pathway to Disaster

Normalization of Deviance occurs when behaviors or practices that were once deemed unacceptable gradually become part of the norm. There can be a significant time lag between the start of deviant behavior and the inevitable consequences. For example, someone might choose not to wear a helmet while riding a motorcycle and get away with it for a long time, but eventually serious injury is likely to occur. Other examples include failing to wear eye and hearing protection, refusing to wear a seatbelt, driving while intoxicated, operating a process outside the operating window, or allowing sub-standard welds to pass. The potential for Normalization of Deviance is vast and extends across both our personal and professional lives – including the hydrocarbon industry, where the stakes for safety and operational discipline are especially high.

When Deviance Leads to Disaster

On February 1, 2003, the Space Shuttle Columbia disintegrated while re-entering Earth’s atmosphere at 10,000 miles per hour, killing all seven astronauts. A $4 billion spacecraft was destroyed, spreading debris over 2,000 square miles and grounding NASA’s shuttle program for 2½ years. The root cause: Normalization of Deviance. Insulating foam strikes were tolerated despite NASA’s clear specifications that no debris should come from the external tank on the launch pad or during ascent. After 113 missions, foam shedding and damage to thermal protection tiles became acceptable as routine, but a critical foam strike during Columbia’s mission fatally damaged its heat shields.

On January 28, 1986, the Space Shuttle Challenger exploded shortly after takeoff, killing all astronauts on board and demolishing the spacecraft. Again, the cause was Normalization of Deviance. Persistent O-ring damage went unaddressed because a backup system was in place, and O-ring damage was accepted as normal. An attitude of “nothing bad has happened yet” existed at high levels of the organization. Despite concerns from technical personnel, schedule pressures and a lack of perceived vulnerability prevailed. Low temperatures on the launch day contributed to the catastrophic failure.

Investigations into both shuttle accidents revealed deep-seated cultural issues at NASA that drove this behavior:

1. The success of past programs fostered a can-do attitude that minimized consideration of failure.
2. Near-misses were regarded as signs of robust system performance rather than warnings of imminent disaster.
3. A weak sense of vulnerability led to complacency, with future successes taken for granted.
4. Extreme pressure to maintain launch schedules permeated the culture.
5. A belief persisted that engineers bore the burden of proving lack of safety.
6. In conflicts between safety and production, production goals consistently took priority.

The Hydrocarbon Industry Isn’t Immune

Normalization of Deviance has also led to serious accidents in the hydrocarbon industry. Two notable examples include elements of the Piper Alpha oil platform disaster, which killed 167 people, and the Flixborough disaster, which resulted in 28 deaths and caused extensive damage outside the fence line.

On the job, we are expected to conform to industry standards, safety rules, operating procedures, and many other requirements. However, lax supervision, poor training, and cost-cutting measures all can open the door to Normalization of Deviance. We often hear excuses like “My boss didn’t care,” “I was never trained to do that,” or “We don’t have the money to do it the right way,” all of which contribute to deviations from Recognized and Generally Accepted Good Engineering Practices (RAGAGEP) and allow Normalization of Deviance to creep into an organization.

The Importance of Vigilance

It’s critical that we learn from past disasters and fight Normalization of Deviance, personally and professionally. At Becht, we can help evaluate your plant to ensure that the right culture, procedures, and practices are in place to prevent deviant behaviors from becoming the norm. With over 1,000 professionals experienced in the refining and petrochemical industries, we stand ready to support your safety and operational goals. Contact our experts today to start a conversation.

This is the second blog article in our series on Normalization of Deviance. Read the first article.

We wish to acknowledge the Center for Chemical Process Safety for input to this blog through the presentation “Lessons from the Columbia Disaster” at the Lyondell 2006 Worldwide Reliability Forum.