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Normalization of Deviance

WEDNESDAY, NOVEMBER 2, 2016

By Warren Brand


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Normalization of deviance: It brought down both Space Shuttles, is responsible for the disaster at Deepwater Horizon and is an insidious issue for many corrosion mitigation failures.

I think a lot. I’m not boasting. I’m lamenting.

I have a mild case of attention deficit disorder (ADD). For me, staying focused on an idea is a lot like trying to catch a canary. Picture a fluttering, yellow canary in a living room. Every once in a while I’m able to snatch it out of mid-air, put it in a cage, sit back and watch it. Study it. Think about it ... until another one flits in through an open window to take my attention away.

Such is my obsession with root-cause issues—and my learning of a concept called Normalization of Deviance.

Trying to Understand Disaster

It started on a Saturday night, when Michelle, my wife of 26 years acquiesced to a “guy flick” and we were off to buttered popcorn, a Coke and a movie: Deepwater Horizon. It’s an engaging portrayal of the tragic, offshore oil platform explosion in the Gulf in 2010, which killed 11 people and led to the worst oil spill in history.

Deepwater Horizon response
By USCG / Public domain via Wikimedia Commons

After watching the movie Deepwater Horizon, I was really interested in finding out how these highly intelligent people allowed this largely preventable event to take place.

The story was gripping and tragic. It was like watching a slow-motion train wreck. I had the same sick feeling in my stomach as I do occasionally when talking to clients.

I remember sitting in on a meeting with a global chemical company as they discussed a tank lining project for the upcoming summer turnaround. I was hawking my firm’s vendor-neutral approach, and—after reviewing their specifications, material selections, etc.—I explained that there were serious flaws, which would lead, almost inevitably to short- and/or long-term problems.

Their response was basically: “We’re too far along the process now, and we can’t afford to hire you. I’m sure it’ll be fine.”

Becoming Accustomed to Deviation

After coming home from the movie, I ravenously searched Google about the root cause of the Deepwater disaster. Google pulled up a lot of technical data of what happened, but what I was really interested in was how these highly intelligent people allowed this largely preventable event to take place.

That’s when I stumbled upon the concept of Normalization of Deviance.

Diane Vaughn coined the phrase in 1996 in relation to the Space Shuttle Challenger disaster, and explained it like this: “Social normalization of deviance means that people within the organization become so much accustomed to a deviation that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety.”

DFT gauge, tank inspeciton
Photos courtesy of Warren Brand unless otherwise specified

I was hired to conduct a condition survey of a large tank that had been lined only about a year earlier. I discovered the owners appeared to have an N-Dev mindset when hiring contractors, no expectations of performance, and had done no inspection during these or many other applications. I was stunned to find that there was no coating anywhere in the tank. Either it dissolved, peeled off or was never applied.

People will sometimes dismiss titles and names as unimportant. “What’s in a name?” they chide. But names are important—really, really important—because once you name something, you’ve identified it. Once you’ve identified it, and can “see” it, you can fix it.

By being able to put a name to something, like Normalization of Deviance (N-Dev), I was able to identify dozens—perhaps hundreds—of examples of it. And like a waterfall, or, perhaps more like Tetris pieces, many past situations neatly fell into this new category of N-Dev events.

The “Necessity” of Inspection Services

Years ago, I wrote a blog about inspection services and inspectors and posed the question, “Are we necessary?”

I think an excellent argument can be made that inspection services exist only because of an industrywide issue with N-Dev.

What else can a failure to abide by a specification be other than individuals and organizations becoming comfortable with doing so? That’s pretty much the definition of N-Dev. Deviation becoming normalized.

It has become normal not to follow the specification and, further, normal to have inspectors find those deficiencies—or at least try. We’ve created an artificial cat-and-mouse game which has led to an upsurge of inspectors, whom many corrosion professionals feel are poorly trained.

All inspectors do, day in and day out, is report on deviations from the norm—the specification. That’s it.

A Systematic, Cultural Malady: Two Case Studies

Case Study 1, Global Entertainment Company

I have met with many individuals who have behaved in a way that made no sense to me. I now understand that these individuals are working in companies where they have simply become, to quote Vaughn, “…so much accustomed to a deviation that they don’t consider it as deviant.”

closeup of no coating

A closeup of the same tank; I looked everywhere for some remnant of a coating system and was shocked to find none.

A perfect example happened during a meeting I had with a global entertainment company. I had been talking with my contact there for months trying to get a meeting. Finally, one was set in Los Angeles with roughly a dozen individuals.

I remain under a very strict non-disclosure, but I can say they have facilities all over the world that require constant painting and upkeep.

I had reviewed their paint choices and specifications months earlier and thought this would be an easy sale. We would clearly save them millions of dollars across the globe in a variety of fashions.

First, they had one facility in Japan that was using roughly 20 percent less paint and associated labor than other facilities. So my bright idea (which anyone not in an environment immersed in N-Dev would see) was to go there and figure out what they were doing differently.

Second, even more of a slam dunk, they were using dozens of different primers from different companies for exactly the same substrate: fiberglass. So, all I had to do was identify one or two low-cost, high-quality suppliers, negotiate pricing based on increased sales, and poof—big savings.

There were other technical issues as well that were more complex. Yet, at the end of the several-hour meeting, the head of design simply said, “Thanks for coming in, but we’re comfortable with how things are going.”

Case Study 2, I Wouldn’t Have Believed It If I Hadn’t Seen It for Myself

About 30 years ago, I began working in the family business (a ginormous mistake, and the fodder for a different blog). At the time, we were lining the interior of underground gasoline storage tanks, mostly at gas stations.

I can think of nothing more commonly used and available, and as unbelievably dangerous, as gasoline. Depending on what internet source you choose to believe, one gallon of gas is the equivalent of between 10 and 14 sticks of dynamite.

typical diaphragm pump for UST job

This image shows a a typical underground storage tank lining project. In the foreground is an orange, pneumatic pump when used properly, is safe to move gasoline from one tank to another.

In 1988, the Federal EPA required all underground storage tanks (USTs) be internally lined, cathodically protected or removed. We were lining a boatload of USTs ranging in size from 1,000 gallons up to 30,000 gallons.

At a typical gas station, the owner would pump out one tank as low as possible, and we would use a grounded, air-powered diaphragm pump to move the remainder into adjacent tanks. We would then hopscotch from one tank to the next. When we got down to the liquid sludge and water (this was before alcohol-based fuels, which absorb water), we would pump the sludge into 55-gallons drums.

One morning, we ended up with several drums full of clean gasoline (I don’t remember why) and I was stunned, speechless and terrified when I watched as one of our guys dropped a small, blue, electric basement sump pump right into a full, open-top 55-gallon drum of gasoline (complete with garden hose), and start to pump gas back into a tank.

I sprinted and about dove to the ground fault circuit interrupter (GFCI) and tripped it. My family member on the site scolded me and reset it. We nearly came to blows as I tore the plug from the wall.

His response: “We’ve always done this, and it’s been fine.” And then, to make matters worse, he insulted me for my “ignorance,” saying, “You’re new here. You don’t know what you’re talking about.”

To this day, if you bring up the topic with my estranged family, they will still say that I overreacted and that it was fine.

They were victims of N-Dev. They had done it so many times before that this suicidal practice had become “normal.”

Case Study 3, Corrosion Mitigation Procurement Decisions

I partner with our clients on a daily basis striving to divine the best methods of addressing corrosion mitigation. And over the years I’ve run into some of the most frustrating situations and stubborn individuals.

Here’s one which I still have trouble wrapping my head around.

electric pump

This is the same type of electric sump pump used to pump highly flammable gasoline out of a 55-gallon drum on a job site many years ago, and which I learned was standard practice for this crew. I still believe it was a miracle no one was ever hurt or killed.

It was about 20 years ago when I was visiting a large corn processing facility. They had a tank of some type that was large enough to drive a small front loader into—which is exactly what they did when replacing the coating system.

The tank was roughly 60 feet in diameter and maybe 40 feet tall. As I recall, it was a wastewater tank, and roughly every eight years they scheduled the complete removal and replacement of a fiberglass laminate system on the floor and thick mil coating system on the walls.

The tank contained mostly water, with some trace amounts of other materials—not particularly challenging from a corrosion prevention perspective.

I owned a coating company at the time and thought this was a slam dunk. What they were doing cost around $350,000 each time. I provided them with a quote for $125,000 and guaranteed the coating, unconditionally, for 10 years. Unheard of, I know, but this was a large facility and we were trying to make an impression. I was also confident that I had identified an optimal material, and we knew how to properly install coatings.

I was frustrated when the client wouldn’t return my calls (this was before email). I finally called his boss who told me, “We’re going to stick with what we’re doing. It’s working fine for us.”

I was speechless. They were using a 20-year-old specification. They were shutting down this tank for weeks every eight years or so and wasting vast amounts of money.

Doing the wrong thing had become normal.

Examples Are Everywhere

I’ve run into this type of thinking often, as I’m sure all of you had. Until I saw the movie Deepwater Horizon and stumbled upon this concept of N-Dev, I attributed it either to stupidity, apathy or someone getting a kickback.

inside a UST

I think an excellent argument can be made that inspection services exist only because of an industrywide issue with N-Dev. What else can a failure to abide by a specification be other than individuals and organizations becoming comfortable with doing so? That’s pretty much the definition of N-Dev. Deviation becoming normalized.

It wasn’t until I recently caged that canary that I recognized what this phenomenon was: Normalization of Deviation (N-Dev). And the insidious part of N-Dev is that when you’re in it, it’s almost impossible to recognize.

Who drives the speed limit? No one. The fact is we’ve discovered that we usually don’t get tickets if we drive, say, only 10 percent over the speed limit. This is N-Dev. It has become normal to speed.

At the corn processing facility, overspending on a tank lining had become normal.

This also happens in the field during coating applications. I cannot tell you how many times I’ve seen old-timers adding solvent to coating systems which clearly indicate not to add any.

I even saw this phenomenon in our current events.

While I understand this is a stretch for a blog on corrosion, I think it’s timely, important, and educational for our readers: the election.                                

My political leanings are complex and irrelevant. But our expectations of what a presidential race should look like have been changed, arguably corroded. Dignity, integrity and a fastidious devotion to truth have been damaged during this election—I hope not irrevocably.

Presidential nominees calling each other “liars” has become routine, mundane and normal. And lying, apparently, has become so commonplace, as to be expected.

Further, there has been a not-insignificant indifference to the facts. People are passionate about their candidates and beliefs, and, unfortunately, instead of looking for the best, most reliable, unbiased resources for data, they tend, now, to look for “facts” that they would like to find, no matter how far afield they must search. They try to find facts to suit their preconceived notions or to support their positions, rather than strive to find the most objective truth possible.

What to Do?

I don’t want to fall into the category of an individual or blogger who simply rants and complains. I’m a root-cause guy, and live to find solutions. So, once we identify an N-Dev situation, what can we do?

Three things:

  1. Develop a slavish devotion to the data. And find the most objective, accurate data you can.  
  2. Act on the data to the exclusion of all else.
  3. Redefine and embrace integrity.

What do you think the massive rush toward autonomous vehicles is? First and foremost, it’s about saving money, but the root cause is to get humans out of the equation—specifically because of N-Dev. I mentioned speeding earlier, but now there’s also texting while driving, and there’s always been some population for which drinking while driving has become “normal.”

When was the last time an airliner crashed because its onboard computer said to itself, Well, yeah, that ol’ left engine is running a little warm, but it’s been okay the last 20 times that happened, so it’s probably fine?

Or maybe you've heard or even said, “You know, that abrasive blast profile is probably okay. I know the humidity was a bit high, but it’s only a one-year warranty, so I’m sure it’ll be fine. I don’t see any rust after all.”

Please share your N-Dev stories. The more we know, the better able we are to provide optimal corrosion mitigation solutions.

ABOUT THE BLOGGER

Warren Brand

Warren Brand’s coatings career has ranged from entry-level field painting to the presidency of two successful companies. Over nearly three decades, he has project-managed thousands of coating installations and developed specs for thousands of paint and coating applications. NACE Level 3 and SSPC PCS 2 certified, Brand, an MBA and martial-arts instructor, now heads Chicago Coatings Group, a leading coatings consultancy. Contact Warren.

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Tagged categories: Business matters; Coating inspection; Consultants; Contractors; Inspection

Comment from trevor neale, (11/3/2016, 2:16 PM)

Hate to think our surgeons use N-Dev !


Comment from Jim Knocke, (11/4/2016, 1:25 PM)

Good article; should have come with a WARNING. I had parallel flashbacks of this years presidential race.


Comment from Tolga DIRAZ, (11/5/2016, 5:12 AM)

One more genuine article from Mr. Warren Brand; I really enjoyed reading from the begining till the end. Especially, I do admire using tragicomical examples of industrial issues you have encountered. Wishing you all the best in your life...


Comment from Bob Buchanan, (11/6/2016, 9:17 PM)

Excellent article. Thanks Warren.


Comment from Warren Brand, (11/7/2016, 9:01 AM)

Hi Trevor. I think it's endemic to all trades and systems. If has happened at NASA, it likely happens in many areas where we hope it would not. Jim - lol, sorry about the absence of a trigger warning. Tolga and Bob - thank you both very much for your kind words.


Comment from Ken Jacobi, (11/7/2016, 9:07 AM)

Another great article, thanks Warren.


Comment from A. Robert Farrow, (11/7/2016, 9:44 AM)

"Depending on what internet source you choose to believe, one stick of dynamite is the equivalent of between 10 and 14 sticks of dynamite." You mean gallon of gas?


Comment from M. Halliwell, (11/7/2016, 12:00 PM)

An excellent article, Warren. My example to add to the list could have been a tragic one, but thankfully wasn't. I was doing an ECO Plan audit on a bridge rehab job. The contractor had a scaffolding system (where the containment would be built once they got to the coatings part of the work) with the scaffold deck being a concerning drop below the bridge deck. They had removed the deck railings to carry out the structural work, but that drop to the scaffolding below caught my attention. I flagged it for the safety team on site and they measured 2.8 - 2.9 m....nope, it was less than the 3 m mandated by the local OHS code, so it was fine and they weren't about to put up a safety railing. I pointed out that the overhang of the scaffolding beyond the deck wasn't that far, that the difference to the code value was tiny (4-8"), the next stop was the river if they missed the scaffolding (10+ m below) and that there were lots of wires and hoses on the deck (tripping hazards). No joy. They were content to do things they way they always had and to be fixated on the single number of the code (3 m). Sure enough, about a week later, someone went over that edge and landed on the scaffolding below, just missing the scaffolding guardrails (they were that close to the edge of the scaffolding). The next time I came out for an audit, wouldn't you know...there was a safety rail along the bridge deck. With so many local companies and related industries using 1.8 m (6') for tie-off height, this one was just mind-blowing. Thankfully no one was seriously hurt....but the potential was there in "doing it the way they had always done it."


Comment from Warren Brand, (11/7/2016, 1:10 PM)

Thanks Ken. Robert - yes, I thought I had caught that. Fixed now.


Comment from Warren Brand, (11/7/2016, 1:14 PM)

Hi M. Halliwell - thanks for sharing. Frightening stuff. I've written several safety plans for firms, specializing in confined space issues. I can't tell you how often I see plumbing companies and/or municipalities working on sewer lines and digging holes deeper than 4' without an angle of repose (of course) and with no shoring. Most of the area around here is clay, but still, it remains concerning. I also remain stunned at how rampant texting while driving is. When we look back at the numbers in a few years, I suspect the incidents of accidents, injuries and death, will dwarf those associated with drunk driving.


Comment from Donald Wroble, (11/7/2016, 2:07 PM)

Good Article! Points are plain common sense. Still see this mentality in many places across the US. The concept of Normalizing Deviance did make me laugh. I thought it was referring to politics too.


Comment from Car F., (11/7/2016, 2:55 PM)

I find this article to be a reflection of our current life-style and practices. At one time no one thought you could buy water in bottles, put a patent on genes, pay to use a road, work 2 hours a day and considered to be “employed” or work overtime, but don’t get paid for it, name a sports facility after a coffee brand or a soda beverage: the unthinkable become normal, in small dosages. Ethical and moral codes, who are compasses of human conduct, have been absorbed, purchased, trade and leased to the point of becoming irrelevant, whether in business, religion or politics. “We’ve always done it like that” is the common mantra of the social idiot: a mentally lazy individual, unimaginative and uncritical of its surrounding: the perfect electorate.


Comment from M. Halliwell, (11/8/2016, 10:50 AM)

Warren, confined and restricted spaces are probably one of the most "red flag" areas that I try not to let NoD anywhere near me (not that it's good anywhere, but that's one that really stands out for me). I had a Prime contractor on a remediation site tell me to "just do whatever you usually do" when I enquired with their project manager about their confined space entry protocols for going into a 13' deep excavation as I needed to collect some samples of hydrocarbon contaminated soil. One wall was concrete, the rest clay and the hole was a good size...cave in wasn't very likely...but poor ingress/egress and potential poor atmosphere were big flags on my list. Needless to say, their site superintendent was flabbergasted when I hauled out the supplied air gear, gas sampling gear, lifelines, harnesses to do it right. It went smoothly, I'm happy to report, but it was just one more example of the slide to "it's fine....we do it all the time." - Michael


Comment from Warren Brand, (11/9/2016, 9:10 AM)

Hi Donald - thank you! Car F. - yup. Michael, yeah. Peer pressure is problematic. I remember years ago I was working over the summer at a small construction company. We were working on an old house - internal demo to the studs. I went into the kitchen where they had started to remove the plaster, and the walls were filled with asbestos. I was stunned and brought it to the attention of the Forman. He, literally, took some in his hand and inhaled it. And said something like, "You pussy. I've been working around this stuff for years." I called the owner, he told me if I wanted to, he could move me to a different job. Over lunch I went to the local library, printed up two dozen articles about the danger of asbestos and handed it out to every worker there. Suffice it to say, it didn't go well. Nearly came to blows with several folks. Of course, I was fired.


Comment from Randy Berthold, (11/9/2016, 10:30 AM)

Well written article Warren. This should strike a cord with many Owners and operators involved with specifications involving protection against potential heavy corrosion & asset loss risk. Gotta go see that movie now...


Comment from Warren Brand, (11/11/2016, 10:46 AM)

Thanks Randy. The movie is well done - and heartbreaking at the same time.


Comment from Jason Hetherington , (1/20/2017, 11:30 AM)

Mr Brand, I very much enjoyed your thoughts on the normalization of deviance. I can't say that "good enough" is inherently human but far too many people operate under the guise. The culmination of these variances typically snowball...resulting in catastrophe. I have first hand experience to failures in both the maritime and coating industries and can attest to the normalization of variance as detrimental.


Comment from Tom Schwerdt, (1/23/2017, 11:07 AM)

Driving is a good example of "normalization of deviance" - 9/11 happens every single month (by # of deaths) spread across US roadways due to human error, except with more crippling injuries. Yet article after article spills across the press about any possible error from moving toward automation - completely ignoring the human-caused carnage.


Comment from Mike Jeffers, (6/5/2017, 10:20 AM)

Good point, Mr. Schwerdt. I attended a course once on process hazard analysis where the instructor made a statement along those lines that has stuck with me ever since. It went something like this - "We like to think we're not okay with killing people, but we really are. Thousands of people die annually in automobile accidents, and we don't think twice about it. Culturally, it's become acceptable for people to die unnecessarily - we just don't like it to happen to a bunch of people in one place at the same time." Kinda blunt but really hits home if you think about it.


Comment from M. Halliwell, (6/5/2017, 12:35 PM)

Mike Jeffers...you make a good point...speeding and DUI deaths are, when looked at through the same glass as occupational deaths, an epidemic of disastrous proportions. There are 27 drunk driving deaths in the US every day...vs. only 13 work related deaths per day. One has become socially acceptable, the other is sometimes looked at as the cost of doing business, but together, they account for 9,855 and 4,745 deaths per year respectively. That's nearly 15,000 deaths per year or 5x the toll of 9/11 every year...yet 9/11 made international headlines while DUI deaths get 2 lines on the back page of the local news...NoD indeed!


Comment from Tom Schwerdt, (6/6/2017, 10:48 AM)

I have high hopes for fully automated driving. The three leading groups seem to be Waymo(formerly Google), Tesla/Nvidia and Mobileye/Intel/Old school auto manufacturers. A fully automated fleet (ie all cars on the road) that killed 35 people a day in the USA would be a vast improvement over the status quo.


Comment from Warren Brand, (6/8/2017, 8:35 AM)

While a bit off topic in terms of corrosion issues, I'm pleased the principal has carried over. I'm an early-adopter of most tech (as long as it's functional) and agree on all counts about automatic driving. I read an article recently that said it may, within 20 or 30 years, be illegal for most people to drive, as drivers would now be the most dangerous variable in the equation. My understanding right now about automated vehicles is the unpredictability of human drivers, and that, right now, if all vehicles were automated, and, able to "speak" together in some fashion (and speak with traffic lights), the system would work fine now . However the first adopters will almost certainly be long-haul trucking, due to the vast financial savings over human drivers. Imagine the cost savings of having a truck drive 24/7 over only being able do drive 8 or 10 hours in a given day.


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