Institutional Memory, Culture, & Disaster

I admit a fascination for reading about disasters. I suppose I’m hoping for the antidote. The little detail that will somehow protect me next time I get into a plane, train, or automobile. A gris-gris for the next time I tie into a climbing rope. Treating my bike helmet as a talisman for my commute. So far, so good.

As human factors psychologists and engineers, we often analyze large scale accidents and look for the reasons (pun intended) that run deeper than a single operator’s error. You can see some of my previous posts on Wiener’s Laws, Ground Proximity Warnings, and the Deep Water Horizon oil spill.

So, I invite you to read this wonderfully detailed blog post by Ron Rapp about how safety culture can slowly derail, “normalizing deviance.”

Bedford and the Normalization of Deviance

He tells the story of a chartered plane crash in Bedford, Massachusetts in 2014, a take-off with so many skipped safety steps and errors that it seemed destined for a crash. There was plenty of time for the pilot stop before the crash, leading Rapp to say “It’s the most inexplicable thing I’ve yet seen a professional pilot do, and I’ve seen a lot of crazy things. If locked flight controls don’t prompt a takeoff abort, nothing will.” He sums up the reasons for these pilot’s “deviant” performance via Diane Vaughn’s factors of normalization (some interpretation on my part, here):

  • If rules and checklists and regulations are difficult, tedious, unusable, or interfere with the goal of the job at hand, they will be misused or ignored.
  • We can’t treat top-down training or continuing education as the only source of information. People pass on shortcuts, tricks, and attitudes to each other.
  • Reward the behaviors you want. But we tend to punish safety behaviors when they delay secondary (but important) goals, such as keeping passengers happy.
  • We can’t ignore the social world of the pilots and crew. Speaking out against “probably” unsafe behaviors is at least as hard as calling out a boss or coworker who makes “probably” racist or sexist comments. The higher the ambiguity, the less likely people take action (“I’m sure he didn’t mean it that way.” or “Well, we skipped that list, but it’s been fine the ten times so far.”)
  • The cure? An interdisciplinary solution coming from human factors psychologists, designers, engineers, and policy makers. That last group might be the most important, in that they recognize a focus on safety is not necessarily more rules and harsher punishments. It’s checking that each piece of the system is efficient, valued, and usable and that those systems work together in an integrated way.

    Thanks to Travis Bowles for the heads-up on this article.
    Feature photo from the NTSB report, photo credit to the Massachusetts Police.