The normalization of deviance

Strategic Finance, May, 2004 by Bob Gunn, Betsy Raskin Gullickson

OVER THE YEARS, THE NATIONAL TRANSPORtation Safety Board has examined hundreds of aviation and other kinds of accidents. As technology has improved, design standards have become more rigorous, and mechanical devices have become more reliable. This leaves us with a stark fact. Human error explains the biggest proportion of wrecks--by far.

Most corporate wrecks are like garden-variety accidents: caused by a small error in judgment that is magnified by a cascading sequence of decisions and actions. They aren't stopped because no one ever questions that first, faulty premise.

NASA has demonstrated this painful lesson twice in our generation--in the explosion of the Challenger Shuttle at launch in January 1986 and the breakup of sister ship Columbia in January 2003--at the combined cost of 14 lives. In both cases, blame ultimately pointed to the culture of the space agency.

One of the specific factors in both disasters was what came to be called "the normalization of deviance." Challenger blew up because of a failure of O-rings (pressure seals in solid rocket motors), which allowed hot gasses to escape and caused the explosion.

NASA and Morton Thiokol, the contractor who made the O-rings, had noted problems in earlier flights. They knew there was a design flaw; they also knew that the malfunction increased under cold conditions. Nevertheless, in flight after flight, nothing really bad had happened. Over time, management increased the amount of damage considered "acceptable." Until the morning, the coldest ever for a Shuttle launch, when ...

"NASA and Thiokol accepted escalating risk, apparently because 'they got away with it last time,'" concluded those who investigated the Challenger disaster. "As Commissioner Feynman observed, the decision making was: 'a kind of Russian roulette ... (the Shuttle) flies (with O-ring erosion) and nothing happens. Then it is suggested, therefore, that the risk is no longer so high for the next flights. We can lower our standards a little bit because we got away with it last time.' ... You got away with it, but it shouldn't be done over and over again like that."

Did NASA learn its lesson? Apparently not. The culprit in the Columbia disaster was damage to the tiles needed to deflect heat during reentry, damage caused when insulating foam broke off from an external fuel tank during launch and hit some tiles. Such impacts had occurred on earlier flights without causing a catastrophe. They had become expected and accepted. Again, until ...

Similarly, an executive makes a faulty judgment call. Maybe there's a miscalculation, and she decides to cover it up, or so much is at stake that she shades a little, just a little. And nobody catches it. When the next quarter rolls around, it seems easy to repeat what worked the last time. One step leads to another and another, until ...

Current headlines chronicle such behavior. As one of the jurors who convicted Martha Stewart told The Wall Street Journal: "We all felt terrible about it at the end. It felt like such a foolish mistake that was increased as it went along."

Sharp is the razor's edge for the leader: The smallest slip may cause a free fall. But even if it doesn't, even if he seems to "get away with it," a leader has placed his foot on thin air when he finds justification for pushing someone to backdate a document, for encouraging the reversal of a bad-debt write-off, or for asking a question that gives the tacit go-ahead for creating a shame transaction.

As leaders, we are confronted with "razor's edge" issues every day, and we make choices in the blink of an eye.

When a leader chooses a deed that points to the greater good, we say that she exhibited good character. That may not seem like such a big deal. Goodness is the default human setting.

But, as humans, we also have the gift of free will: We aren't compelled to act just because we happen to have a particular thought. We can stop, consider, then proceed. That sets us apart from the "animal world," which apparently lacks the ability to reflect.

The power to choose can be used for good or evil purposes--to serve others or to use people to further our own selfish desires.

So how does a leader learn to walk the "razor's edge"? No matter what the circumstance or how great the pressure to do something right now, how do we learn to make the right choice?

Certainly the expression "good judgment comes from experience; experience comes from bad judgment" may be familiar. Reflecting on those times when the wrong choice was made can be a powerful learning process. Bad choices get imprinted in the brain as "feeling" memories that, when sensed again, raise the inner alarm of caution. The mindful leader will pause and reflect, looking for a choice other than the perilous path previously taken. She allows herself to be nudged away from danger, turned away from the cliff by a deeper wisdom.

Another way to re-learn how to make a right choice is by associating a set of feelings with the words describing right actions--words such as: