“It must be remembered that there is nothing more difficult to plan, more doubtful of success, nor more dangerous to manage than a new system. For the initiator has the enmity of all who would profit by the preservation of the old institution and merely lukewarm defenders in those who gain by the new ones.” ― Niccolò Machiavelli

On January 28, 1986, the space shuttle Challenger broke apart seventy-three seconds into its tenth flight and disintegrated over the Atlantic Ocean, killing all seven crew members aboard.  The disintegration was a result of a failure of a booster rocket O-ring seal; a failure that was predicted prior to the Challenger’s failed flight.  A burn-damaged O-ring was first discovered following the second shuttle mission and NASA, under immense schedule pressure, decided they could correct the problem without the required grounding the fleet. When the next several missions flew with no O-ring anomalies, that decision was reinforced.  Over the next several years, more O-ring sealing problems were observed. However, with each successful flight the perception that it was safe to continue flight operations was emphasized until the day of the Challenger tragedy in 1986.  As the investigation into the disaster ended, eyes turned to NASA and a phenomenon known as the normalization of deviance.

What Happened?

Why would the NASA employees, who were aware of the O-ring anomalies, choose to continue the flights when they were cognizant of the danger?  Diane Vaughan answers that question by defining normalization of deviance as a point when “people within the organization become so accustomed to a deviant behavior that they don’t consider it deviant, despite the fact that they far exceed their own rules for the elementary safety.”  Over time, with lack of repercussion, continuing flights despite o-ring anomalies became the norm.  While NASA and the Challenger are glaring examples of this phenomenon, it can occur within any organization.  We’ve all heard the phrase “It has always been that way.”  Typically, this is how an employee acknowledges that maybe the method isn’t the right one, but that’s how they were shown, it works, and they are going to continue to do it that way.  The problem with saying that it has always been that way is that, in truth, it hasn’t.  So, why did the original deviant behavior occur?


Shortcuts are commonplace in any activity we take part in.  The desire to be more efficient, to complete a task with less time and effort than originally required – all while achieving the same result, is part of human nature.  Oftentimes, however, shortcuts come with risks.  Whether they are risks to safety or quality, taking a shortcut is a calculated decision of risk versus benefit.  Within an organization, shortcuts are driven by several components, urgency being the biggest contributing factor.  The sense of urgency is derived from strains such as the pressure to meet schedule requirements, the insistence to conform to budgetary considerations, or the burden of delivering on a promise all while being expected to adhere to required standards or prescribed procedure.  Shortcuts are often justified by the “just this once” frame of mind, but with repetition and reward they can become part of everyday routine.


When a shortcut is taken in response to pressures and the pressures do not abate, the shortcut may be repeated again and again.  Each time it is repeated and there are no adverse consequences, if the outcome is favorable then the shortcut is deemed a success.  The problem with this success, however, is that it is based on luck and not skill.  For instance, a construction worker is on the job site and needs a long ladder, but the long ladder is not readily available.  However, nearby and easily accessible is a short ladder.  Whether it be due to the pressure of a production goal, the convenience, or various other reasons, he chooses the shorter ladder, against his better judgement, and improvises.  When the ladder doesn’t fail, it makes the decision to use the ladder again the following day easier.  Each use of the shorter ladder that passes without incident serves to reinforce the shortcut until it eventually becomes the norm.  The success of the shortcut is unrelated to the skill of the construction worker using the ladder.  Instead, it’s a direct result of fortunate conditions that the ladder has remained upright as it was being used outside its intended purposes.  As long as the outcome continues to be favorable, the shortcut is continually supported through reward.


Aleksandr Solzhenitsyn said “It is in the nature of the human being to seek a justification for his actions.” If you ask an employee why they took a shortcut, almost one hundred percent of the time, they are going to defend their actions with rationale.  Sometimes it’s because knowledge is imperfect and uneven; perhaps the only way the employee knows how to complete the task is with the shortcut that a senior coworker showed them.  Other times it’s because they believe the rules to be “stupid” or “inefficient” and they are breaking the rules for the good of the team, the company, the timeline, the bottom line, etc.  Maybe they’ve seen a coworker breaking the rules with no repercussions, disciplinary or otherwise. No matter the reason, there are no justifications for shortcuts that deviate from the official policies and procedures.  These attempts at justification only serve as an attempt to persuade us that the actions we chose were appropriate when we were aware that they were not.

The New Norm

When deviations become the new norm, what can we do to step in and restore the system?  How do we make the original system new again?  The first step is to make sure your Standard Operating Procedures (SOPs) are accurate, efficient, and up to date.  Training and knowledge are key as well.  It is more difficult for an employee to follow a SOP if they are not entirely familiar with its content, which makes them more likely to deviate from the procedure or follow shortcut examples of coworkers.  Employees must be provided with the tools they need to succeed.  They also must be given realistic and attainable goals.

If you are an employee, follow your SOPs or learn to adapt to changes in them.  Just because something has “always been that way” doesn’t mean that’s the way it should continue to be.  Don’t be afraid to speak up.  Be an advocate for safety and structure.  Change is never easy and there is almost always resistance, but patience, adaptation, and communication can break the deviant cycle.


  • Kayla Whelehon

    Kayla began her career with Bluefield Process Safety in 2016. Her interest in the field began with the commencement of her husband’s career as a process safety consultant.