from Hacker News

Diane Vaughan and the normalization of deviance

by samueladam on 7/15/19, 3:14 PM with 3 comments

• by PaulHoule on 7/15/19, 5:58 PM

  Vaughn's "normalization of deviance" involving the space shuttle was a top-down process of "We have a list of unacceptable risks that we have to accept, and having meetings to manage these." Given that the shuttle had fundamental flaws (e.g. it was the only manned space vehicle that didn't have an escape system) that was the best they could do other than deciding that they weren't going to fly it.

  It was inevitable, however, that one of the unacceptable risks was going to bite them, and it did, twice.

  The term "normalization of deviance" is frequently used in the health care context to describe something entirely different, a bottom-up process. That is, nurses and doctors don't wash their hands, skip steps, etc. Upper levels of the institution might fail to control this behavior, but it's a different horror.

• by closeparen on 7/15/19, 5:52 PM

  The flip side of the normalization of deviance is the normalization of policies and procedures that have no regard for on-the-ground reality. Sometimes eliminating deviance is a devastating form of labor action: https://en.m.wikipedia.org/wiki/Work-to-rule

• by kryogen1c on 7/15/19, 5:20 PM

  To quote from a paper I read and love but cannot find, Meditations and Reflections of a Naval Reactors Engineer (i would pay money for):

  Because everyone cares deeply about about their jobs, mistakes tend to be either extremely subtle or extremely glaring.

  Normalization of deviance leads to the latter, although for different reasons. It is to prevent things like this that the nuclear navy forces people to rotate commands every few years.