Mullane was selected as a Mission Specialist in 1978 in the first group of Space Shuttle Astronauts. He completed three space missions aboard the Shuttles Discovery (STS-41D) and Atlantis (STS-27 & 36) before retiring from NASA and the Air Force in 1990. Mullane has been inducted into the International Space Hall of Fame and is the recipient of many awards, including the Air Force Distinguished Flying Cross, Legion of Merit and the NASA Space Flight Medal.
Presentation Description & Topics
Guarding Against the Normalization of Deviance
A safety program by Astronaut Mike Mullane
Astronaut Mullane delivers a powerful message on the individual’s role in keeping themselves and their teams safe in hazardous environments. Mullane introduces this subject with a recount of his own near-death experience in a fighter jet, when he failed to speak up about an unsafe situation. He assumed another crewmember, with more flying time, knew best about the safety of their operations. In other words, at a critical moment in a hazardous operation, Mullane surrendered his responsibility for safety to someone else. He became a “passenger”. The result was his (and the pilot’s) narrow escape from death during their ejection from the crashing jet. The destruction of a multi-million dollar plane might have been avoided if Mullane had maintained his safety presence and voiced his assessment on the dangers of the situation. Instead, he assumed the pilot’s position of authority and longevity of flying hours counted more than his analysis of the situation.
Mullane continues this thread: that each individual brings to their team a unique perspective on safety. Only when every person’s perspective is available for analysis can a team be truly safe. When it comes to safety everybody counts, regardless of their position or longevity.
Another significant message within Mullane’s Safety program is his discussion on “Normalization of Deviance”. Mullane uses the space shuttle Challenger disaster to define this term, its safety consequences, and how individuals and teams can defend themselves from the phenomenon.
Challenger was the result of a failure of a booster rocket O-ring seal. Viewers will be shocked to know this failure was predicted: “It is my honest and very real fear that if we do not take immediate action to solve the problem, with the O-ring having the number one priority, then we stand in jeopardy of losing a flight along with all the launch pad facilities.” (From a NASA-contractor memo dated six months prior to Challenger).
When a burn-damaged O-ring (a criticality 1 or “grounding” deviance) was observed following the second shuttle mission, NASA, under enormous schedule pressure, convinced themselves the problem could be fixed with minor modifications to booster assembly procedures. When the next several missions flew without O-ring anomalies, the correctness of the decision to continue operations was reinforced. However, over the following several years, more cases of burn-damaged O-rings were observed in the returned boosters but with each successful flight the false feedback that it was safe to continue flight operations was strengthened. In other words, the absence of something bad happening was being falsely interpreted as an indication that the team’s actions were safe when, in fact, it was mere random chance that a disaster hadn’t occurred. The team had gotten away with accepting a criticality 1 deviance so many times, the deviance had been normalized into the team’s decision-making process. Challenger was a “predictable surprise”.
After dramatically defining “Normalization of Deviance”, Astronaut Mullane continues with an explanation of how individuals and teams can defeat this dangerous phenomenon through these practices: recognizing one’s vulnerability to it; planning the work and working the plan under an umbrella of situational awareness; listening to people closest to an issue; communication – if you see something, say something; and, archiving and periodically reviewing near-misses and disasters so the corporate memory never fades. (Mullane explains that the loss of the space shuttle Columbia…17 years after Challenger…was a repeat of “Normalization of Deviance”. NASA’s corporate memory had faded over those 17 years.)
These messages delivered are reinforced with rarely seen NASA video and slides. The program is visually captivating, hard-hitting and fast paced. There are also periodic breaks in the serious message in which Mullane humorously shares various stories about living and working in space. “Guarding Against the Normalization of Deviance ” is certain to open the eyes of every viewer to their individual criticality to team safety.