[throw1234651234]

There is also something called "Normalization of Deviance", defined better by a quote: "Today, the term normalization of deviance — the gradual process by which the unacceptable becomes acceptable in the absence of adverse consequences — can be applied as legitimately to the human factors risks in airline operations as to the Challenger accident." *

Most of you have probably heard of it in the context of fighter pilots doing riskier and riskier maneuvers, but it seems to apply to drivers who speed a lot. 80 starts seeming really slow to them after doing it for years.

* https://flightsafety.org/asw-article/normalization-of-devian....

[Litost]

Thanks for posting these, I'd only seen Normalisation of Deviance mentioned in these two youtube videos by Mike Mullane and never thought to look any further:

https://www.youtube.com/watch?v=Ljzj9Msli5o

https://www.youtube.com/watch?v=jWxk5t4hFAg

and the uploader references some further links:

https://www.fireengineering.com/leadership/firefighter-safet...

https://www.flightsafetyaustralia.com/2017/05/safety-in-mind...

and references this book (about the Challenger Disaster):

https://www.amazon.com/gp/product/B011DAS53Y/

which has an overview here:

http://web.mit.edu/esd.83/www/notebook/The%20Challenger%20La...

including these two excerpts I found interesting in this context: "Chapter nine she explains how conformity to the rules, and the work culture, led to the disaster, and not the violation of any rules, as thought by many of the investigators. She concludes her book with a chapter on lessons learned."

"She mainly emphasizes on the long-term impact of institutionalization of the political pressure and economic factors, that results in a “culture of production”."

[PaulHoule]

Vaughn's book The Challenger Launch Decision doesn't tell this truth: the root cause of the accident can be traced back a decade to the acceptance of a design that was "unsafe at any speed".

Every other manned space vehicle had an escape system. The crew of the Challenger was not killed by the failure of the SRB or the explosion of the external tank, but rather when the part of the orbiter they were in hit the ocean. They could have build this into a reinforced pod with parachutes or some other ability to land but they chose not to because they wanted to have the payload section in the rear.

In the case of Columbia it was the fragile thermal protection system that did the astronauts in. There was a lot of fear in the first few flights that the thermal tiles would get damaged and failed and once they thought they'd dodged that bullet they didn't worry about it so much.

"Normalization of deviance" was a formal process in the case of the space shuttle of there being meetings where people went through a list of a few hundred unacceptable situations that they convinced themselves they could accept, often by taking some mitigations.

When the design was finalized it was estimated that a loss of vehicle and crew would happen about 2%-3% of the the time which was about what we experienced. (Originally they planned to launch 50 missions a year which would have meant the continuous trauma of losing astronauts and replacing vehicles.)

It's easy to come to the conclusion that it was a particular scandal that one particular concern got dismissed during a "normalization of deviance" meeting but given a poorly designed vehicle it was inevitable that after making good calls for thousands of concerns there would be a critical bad call.

"Normalization of deviance" is frequently used for a phenomenon entirely different than what Vaughn is talking about, something informal that happens at the level of individuals and small groups. That is, the forklift operators who come to the conclusion it is OK to smoke pot at work, the surgeon who thinks it is OK to not wash his hands, etc. A group can pressure people to do the right things here, but it's something different from the slow motion horror of bureaucracy that tries to do the right thing but cannot.