Ludwig on Leadership: The Normalization of Deviance

If you’re old enough, you might remember when the Space Shuttle Challenger blew up on January 28, 1986, killing seven astronauts, including a civilian school teacher. I was on my off day when I watched it live on CNN. It seemed surreal. There were 24 Space Shuttle flights prior to the Challenger disaster, and launching shuttles had come to seem like an everyday event. They were launching once every 4–5 months. How could something that had become so customary and routine have such a devastating accident?

President Ronald Reagan commissioned the Presidential Commission on the Space Shuttle Challenger Accident, also known as the Rogers Commission. What they discovered was the O-rings, which created seals where the different sections of the solid rocket booster were joined together, failed. This allowed pressurized hot gases and eventually flames to “blow by” the O-ring and make contact with the adjacent external tank, causing structural failure of the tanks. The failure of the O-rings was attributed to faulty design and low temperatures on the day of launch.

There were many failures. Engineers at NASA and Morton Thiokol, the company that designed the solid rocket boosters, ignored warnings about potential issues with the putty used to seal the O-rings. Countless memos and other documentation showed the O-ring failed and leaked gases in more than half of previous shuttle launches. Each time this happened, the deviation from what should have been the standard was classified as an acceptable risk because nothing happened. The more nothing happened with the O-rings, the more common it became for NASA to ignore the problem, since it was a normal way of doing business.

Such thinking and actions have been called the normalization of deviance. If you take a risk and nothing bad happens, it becomes the common way of doing things. The Challenger is not the only example of this; there have been other major disasters, such as the grounding of the cruise ship Costa Concordia and countless smaller events, that have been attributed to the normalization of deviance.

EMS is no different. Leadership of an EMS organization can allow normalization of deviance that one day may result in a bad outcome. How, you ask?

There are endless examples. How many ambulance crews come to work in the morning and, instead of checking to make sure they have everything on the ambulance, take the offgoing crew’s word for it that everything is there? Those crews will sit down, have breakfast, check their Facebook or Twitter, or do everything else besides ensuring everything they need is on the ambulance.

This can go on for months or even years without consequences. Even when they go on a call, they might find something missing or something they need, but it does not affect the patient’s outcome. They just adjust on scene. Months or even years later, though, their first call of the morning is a cardiac arrest, and when they go to hook up the monitor-defibrillator, they find the batteries are dead.

If they had only checked their ambulance at the start of their shift, this problem could have been averted! But it became normal to not worry about checking out the ambulance at the start of their shift. The more they did it without a bad outcome, the less concern they had—until that one time. Unfortunately, the patient died or had no chance at resuscitation because it became normal for the paramedics to deviate from what should have been the standard.

How do you avoid normalization of deviance as the EMS manager? The first thing is to make sure all your standard operating procedures (SOPs) and rules are updated and that all employees know what they are. Throwing memos at staff and then telling an employee who’s been with your EMS agency one year that they violated a memorandum written five years ago does not make much sense.

Make sure employees are held to the standard of meeting the SOPs and rules within your agency. You also need to listen to your employees. You need to hear what works and what does not work. Many times those employees will have solutions to problems they’re telling you about. Lastly, sometimes having someone from the outside come in and look at your operation can help identify the normalization of deviance.

As the EMS manager, one of your priorities should be preventing bad things from happening. Dealing with normalization-of-deviance issues can help accomplish this.

Gary Ludwig, MS, EMT-P, is chief of the Champaign (IL) Fire Department. He is a well-known author and lecturer who has managed award-winning metropolitan fire-based EMS systems in St. Louis and Memphis. He has a total of 37 years of fire and EMS experience and has been a paramedic for over 35 years. Contact him at garyludwig.com.

f you’re old enough, you might remember when the Space Shuttle Challenger blew up on January 28, 1986, killing seven astronauts, including a civilian school teacher. I was on my off day when I watched it live on CNN. It seemed surreal. There were 24 Space Shuttle flights prior to the Challenger disaster, and launching shuttles had come to seem like an everyday event. They were launching once every 4–5 months. How could something that had become so customary and routine have such a devastating accident?

President Ronald Reagan commissioned the Presidential Commission on the Space Shuttle Challenger Accident, also known as the Rogers Commission. What they discovered was the O-rings, which created seals where the different sections of the solid rocket booster were joined together, failed. This allowed pressurized hot gases and eventually flames to “blow by” the O-ring and make contact with the adjacent external tank, causing structural failure of the tanks. The failure of the O-rings was attributed to faulty design and low temperatures on the day of launch.

There were many failures. Engineers at NASA and Morton Thiokol, the company that designed the solid rocket boosters, ignored warnings about potential issues with the putty used to seal the O-rings. Countless memos and other documentation showed the O-ring failed and leaked gases in more than half of previous shuttle launches. Each time this happened, the deviation from what should have been the standard was classified as an acceptable risk because nothing happened. The more nothing happened with the O-rings, the more common it became for NASA to ignore the problem, since it was a normal way of doing business.

Such thinking and actions have been called the normalization of deviance. If you take a risk and nothing bad happens, it becomes the common way of doing things. The Challenger is not the only example of this; there have been other major disasters, such as the grounding of the cruise ship Costa Concordia and countless smaller events, that have been attributed to the normalization of deviance.

EMS is no different. Leadership of an EMS organization can allow normalization of deviance that one day may result in a bad outcome. How, you ask?

There are endless examples. How many ambulance crews come to work in the morning and, instead of checking to make sure they have everything on the ambulance, take the offgoing crew’s word for it that everything is there? Those crews will sit down, have breakfast, check their Facebook or Twitter, or do everything else besides ensuring everything they need is on the ambulance.

This can go on for months or even years without consequences. Even when they go on a call, they might find something missing or something they need, but it does not affect the patient’s outcome. They just adjust on scene. Months or even years later, though, their first call of the morning is a cardiac arrest, and when they go to hook up the monitor-defibrillator, they find the batteries are dead.

If they had only checked their ambulance at the start of their shift, this problem could have been averted! But it became normal to not worry about checking out the ambulance at the start of their shift. The more they did it without a bad outcome, the less concern they had—until that one time. Unfortunately, the patient died or had no chance at resuscitation because it became normal for the paramedics to deviate from what should have been the standard.

How do you avoid normalization of deviance as the EMS manager? The first thing is to make sure all your standard operating procedures (SOPs) and rules are updated and that all employees know what they are. Throwing memos at staff and then telling an employee who’s been with your EMS agency one year that they violated a memorandum written five years ago does not make much sense.

Make sure employees are held to the standard of meeting the SOPs and rules within your agency. You also need to listen to your employees. You need to hear what works and what does not work. Many times those employees will have solutions to problems they’re telling you about. Lastly, sometimes having someone from the outside come in and look at your operation can help identify the normalization of deviance.

As the EMS manager, one of your priorities should be preventing bad things from happening. Dealing with normalization-of-deviance issues can help accomplish this.