Normalization of Deviance

Specifically, the normalization of deviance process in Challenger Launch Decision involved a 5-step process:

1. Signal of potential danger
2. Official act acknowledging potential danger
3. Review of the evidence
4. Official act indicating the normalization of deviance (i.e. accepting the risk)
5. Shuttle launch

The key thing that Vaughan identifies is that in every iteration of the above cycle, the standard that was compared against was the output of the previous iteration. Because of this, the notion of what was "acceptable" joint rotation subtly shifted over time, from what a conservative standard in 1977 to a very risky one 1986. The problem was that NASA was updating its beliefs about what was acceptable O-ring performance, but, as an organization, was not realizing that it had updated. As a result it drifted in an uncontrolled manner from its original standards, and thus signed off as safe a system that was, in retrospect, a disaster waiting to happen.

Normalization of deviance is a difficult problem to combat, because the process that leads to normalization of deviance is also the process that leads to helpful and beneficial updates about the state of the world. I would suggest that some normalization of deviance, within limits is acceptable. The world is not always going to be what your model says it will be, and you have to have some leeway to adapt to circumstances that aren't what you were expecting. However, when doing so, it's important to ensure that today's exception remains an exception, and that the next time deviance occurs, it's checked against the original standard, not an updated standard that results from the exception process.

I was shocked to hear about doctors in hospitals not washing their hands (from a medical student who was shocked to see it during his internship), and when I discussed it privately with some doctors, they told me it all depends on the boss. When the boss in the hospital washes his hands religiously, and insists that all employees must wash their hands all the time, they will. But when the boss ignores this norm, then... ignoring the norm becomes a local symbol of status. So the norm within the same hospital may change dramatically in short time, in either direction, when the boss is replaced.

I saw a similar thing in software projects. You almost always have a list of "best practices", but it makes a big difference whether the highest-status developer is like "we do this all the time, no exceptions", or -- much more frequently -- he is like "of course, sometimes it doesn't make much sense to ... ", and of course the scope of "sometimes" gradually expands, and it becomes a symbol of high status to not write unit tests. You can have two projects in the same company, with the same set of "best practices" on paper, with the same tools for automatically checking conformance (only, in one team, sending of the error messages is turned off), and still dramatically different code quality.

(And actually this reminds me of a time period when making fun of "read the Sequences" was kinda high-status here. I don't hear it recently, and I am not sure what it means: maybe everyone read the Sequences, or everyone forgot about them so that the joke is no longer funny because no one would know what it refers to, or maybe both sides just ageed to not discuss this topic publicly anymore.)

This is important We don't spend enough time thinking about WHY values drift or rule-violations get normalized. Use of "deviance" as a descriptor implies that the initial stated rule is correct and the deviations are undesirable. I'd argue that this is rarely the case - most rules and procedures are both oversimple (don't cover many common situations) and incorrect (are not optimal even for common situations).

IMO, if you're trying to establish a habit or live up to an ideal, there are two types of exception: those that actually improve the outcome (whatever reasons you have for trying those things), and those that recognize tradeoffs not considered in the initial establishment. The first kind of exception is good, IMO - you can meet your goal better with a more complicated model. The second kind can be good or bad, depending on your weighting of the tradeoffs.

I thought it might be useful to give an example of when normalisation of deviance is functional. Let's suppose that a hospital has to treat patients, but because of short-staffing there would be no way of filling out all of the paperwork properly whilst treating all the patients, so the doctors don't fill out all of the fields.

It's also important to mention the possibility of scapegoating - perhaps the deviance is justified and practically everyone is working in that manner, but if something goes wrong you may be blamed anyway. So it's very important to take this small chance of an extremely harsh punishment into account.

I just wonder if it might be worth distinguishing between personal and social modes of this behavior. Not sure here though. Initially my thought on your first two examples were they are not really normalized deviations but simply poor discipline -- and somewhat still view them as that. The point about allowing some slack, however, is important to keep in mind here too. (Plus there are other aspects here -- like is the habit to be formed really something one wants or just thinks they should want it because its some general consensus or it works for other people).

Much of your view here does seem to apply to the environment in which I work and always find myself oscillating between thinking I need to try to help enforce the stated rule/goal/behavior and realizing it is not to be taken at face value and interpreted in a slightly different way (that would be a deviation from the ostensible policy. I find it very difficult though, it creates a lot of frustration for me and a sense of cognitive dissonance for me mentally.

Good article I recently came across about normalization of deviance in safety settings where it can produce a "drift towards danger".