Professionalism/Diane Vaughan and the normalization of deviance

Diane Vaughan is an American sociologist who devoted most of her time on topics as different as "Tension in private life" and "Deviance in organizations". She states, "I find that in common, routine nonconformity, mistake, misconduct, and disaster are systematically produced by the interconnection between environment, organizations, cognition, and choice. These patterns amplify what is known about social structure and have implications for theory, research, and policy". One of Vaughan's theories regarding misconduct within large organizations is the normalization of deviance.

Diane Vaughan
Diane Vaughan is a professor at Columbia University's Department of Sociology. "Diane Vaughan received her Ph.D. in Sociology, Ohio State University, 1979, and taught at Boston College from 1984 to 2005. During this time, she was awarded fellowships at Yale (1979-82), Centre for Socio-Legal Studies, Oxford (1986-87), the American Bar Foundation (1988-1989), the Institute for Advanced Study, Princeton (1996-1997), and John Simon Guggenheim Memorial Foundation (2003-04). She came to Columbia in 2005. Her most recent endeavors include using qualitative data, such as interviews, to research how large groups, or organizations, affect the decision making of the individual.

Description of Normalization of Deviance
"Social normalization of deviance means that people within the organization become so much accustomed to a deviant behavior that they don't consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety". People grow more accustomed to the deviant behavior the more it occurs. To people outside of the organization, the activities seem deviant; however, people within the organization do not recognize the deviance because it is seen as a normal occurrence. In hindsight, people within the organization realize that their seemingly normal behavior was deviant.

The Challenger Launch Decision
Diane Vaughan developed her theory of the normalization of deviance in The Challenger Launch Decision. She details how, during the developmental phase of the Space Shuttle Program, the normalization of deviance resulted in a dangerous design flaw in the design of the spacecraft. The group that was assessing the joints on the solid rocket boosters conducted analysis to find the "limits and capabilities of joint performance. Each time, evidence initially interpreted as a deviation from expected performance was reinterpreted as within the bounds of acceptable risk". The acceptance of this risk led to the Challenger exploding on the morning of January 28, 1986.

Morton-Thiokol was contracted by NASA to manufacture the Solid Rocket Boosters (SRB) that were used in the Space Shuttle Program. In 1981, a problem with the putty that was used to seal the O-rings on the SRBs was discovered. When the putty was added to the boosters, bubbles formed. During take-off, the gases from inside of the SRB would go through the bubbles resulting in a "localized high temperature jet which was drilling a hole right into the O-ring". Morton-Thiokol changed the putty and the method of putty application and considered it fixed. The engineers knew that the putty erosion could still occur, but with a very low probability of a catastrophic disaster. NASA determined that the erosion of the putty was an acceptable risk of flight. NASA and Morton-Thiokol characterized the erosion as an anomaly that was to be expected since the SRBs were such a new technology. Subsequent test flights showed putty erosion that was deemed acceptable by NASA and Morton-Thiokol even though the joint actually "deviated from expected performance".

NASA and Morton-Thiokol suffered from the normalization of deviance when assessing the safety of the SRBs. Diane Vaughan states, "As [NASA and Morton-Thiokol] recurrently observed the problem with no consequence they got to the point that flying with the flaw was normal and acceptable". On January 28, 1986, the normalization of deviance within the two organizations contributed to the loss of the Space Shuttle Challenger and the seven astronauts on board.

Isabella Stewart Gardner Museum Art theft of 1990
On March 18, 1990 the most sensational art heist in U.S. history occurred. The Isabella Stewart Gardner Museum in Boston let two thieves posing as police officers into the building at 1:24 AM which resulted in paintings and other works of art, including three Rembrandts and a Vermeer being stolen. The value of the haul was estimated at between $300 and $500 million. As of this writing, none of the art has been recovered. The guard sitting at the security control desk was a then-23-year-old Berklee College of Music student. In an interview, he called the job, “the most boring in the world,” and admitted that he frequently arrived at work stoned on marijuana, although not on the morning in question. The guard at the desk said, “he decided to let them in because he felt compelled to obey a police officer's demand.” The problem was he was breaking two major rules: (1) Never allow anyone into the Gardner after hours who hadn’t been summoned by museum staff; and, (2) never leave the security desk unattended. Leadership at the Gardner was well aware of this appalling security weakness because a formal recommendation to move the entire security system into a control room accessible only to those with pass keys was submitted to the museum director the year before.

This is example of normalized deviance, when protocol or rule violations that allow errors or other kinds of “toxins,” like thieves, to exploit the system is confirmed time and again. System operators become careless and lackadaisical from nonevents; the guards were not trained or were inexperienced; they claimed not even knowing what to do if police showed up unannounced, although the rule about refusing entry into the museum was clearly stated in the security manual. This demonstrates that professionals who perform rule-bound tasks, especially associated with complex and risky interventions whose failures can invite serious harm and injury, must appreciate the perils of deviating from standards of care. The more such deviations are allowed, the more normalized they become. This shows that that deviant practices in the form of violations of rules and practice standards are arch contributors to the theft.

The Crash of the Costa Concordia
The cruise ship Costa Concordia crashed off the coast of Italy on January 13, 2012. This disaster killed thirty-two of the 4,252 passengers on board. The sinking can be attributed to negligence of the Captain and crew. Their actions were all because of the normalization of deviance in the cruise business. Captain Francesco Schettino first decided to go on an unapproved course because it was a tradition for cruise ships to pass the particular island closely. Passing closely created a spectacle for the people on the shore. This behavior was the norm, but each captain was deviating from their approved path. The captain also made another mistake after he hit the reef because he didn't call for an abandon ship until later than necessary. The evacuation should have taken no more than an hour but became panicked after the ship ran aground. The hectic evacuation made for many mistakes by captain and crew. The captain even left the ship before all the passengers and crew were evacuated. Because of the culture of negligence on the ship, the disaster became much larger than it may have been otherwise.

Normalization of Deviance in Health Care
Normalized deviance has been a major problem in health care. For example there are problems such as failing to check or record a lab finding, ordering the wrong drug, or entering a lab finding in the wrong patient’s chart are usually not enough to guarantee an occurrence of harm. An example of this is when a third-year medical student stated “I was observing what turned into a very difficult surgery. About 2 hours into it and after experiencing a series of frustrations, the surgeon inadvertently touched the tip of the instrument he was using to his plastic face mask. Instead of his requesting or being offered a sterile replacement, he just froze for a few seconds while everyone else in the operating room stared at him. The surgeon then continued operating. Five minutes later he did it again and still no one did anything. I was very puzzled, but when I asked one of the nurses about it after the operation, she said, “Oh, no big deal. We’ll just load the patient with antibiotics and he’ll do fine.” And, in fact, that is what happened; the patient recovered nicely”.

We can use health as an example of a reason why deviance is normalized in companies. Here are four major reasons why it happens:


 * 1) "The rules are stupid and inefficient." System operators will often invent shortcuts or workarounds when the rule, regulation, or standard seems irrational or inefficient.
 * 2) Knowledge is imperfect and uneven. System operators might not know that a particular rule or standard exists; or, they might have been taught a system deviation without realizing it.
 * 3) "I’m breaking the rule for the good of my patient!" This justification for rule deviation  is where the rule or standard is perceived as counterproductive.
 * 4) Workers are afraid to speak up The likelihood that rule violations will become normalized obviously increases if persons who witness them refuse to intervene. Yet, a 2005 study of more than 1,700 healthcare professionals found that “it was between difficult and impossible to confront people”.

Solutions
Ignorance across the organization is the problem, and hence education is the best solution for the normalization of deviance. Diane Vaughn states, "the ignorance of what is going on is organizational and prevents any attempt to stop the unfolding harm." Being clear about standards and rewarding whistle blowers is part of the education that should take place. A company must be transparent about their standards and consequences of not meeting them. Also, creating a culture that is less individualistic and more team-based is helpful to stop the normalization of deviance. Each person should be looking out for the company and team as a whole. If it were more team-based, each person would feel like they were letting their colleagues down if they were to break the rules. A top-down approach is very important. If the employees see executives breaking rules, they will feel it is normal in the company's culture. Normalization of deviance is easier to prevent than to correct. Companies must make sure they take the correct steps to prevent it.