Leadership and the Normalization of Deviance: Step off the Ladder

Transcription

1 Leadership and the Normalization of Deviance: Step off the Ladder

2 Organizational Traps

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11 Theories-In-Use vs Espoused Theories

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18 The Ladder of Inference

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20 I will follow up questions to confirm my assumptions. I think he doesn t speak up in meetings to avoid confrontation. I don t trust him. I think he is distracted because he doesn t agree. I add meaning, he seems distracted. I select some data and ignore other data. In a meeting someone taking notes, someone shifting in their chair, someone texting on their phone.

21 Get in the habit of moving down the ladder! Questions your assumptions and conclusions. Seek contrary data.

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23 How do we avoid climbing the Ladder of Inference? 1. Become more aware of your own thinking and reasoning (reflection); 2. Make sure that others understand your thinking and reasoning (advocacy); 3. Ask questions of others about what they are thinking, and test your assumptions

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25 Normalization of Deviance

26 The Space Shuttle program was very expensive. How do you make these missions self-funding, targeting 60 missions per year? The shuttle could take materials into space and private companies would offset that cost.

27 And the space shuttle could return and do this again and again. But, the pressure to launch and stay on schedule became a priority at the expense of other critical safety concerns. NASA never exceeded 9 missions in one year Jim DeLung, LLC

28 It s chilly in Florida Icicles formed on the pad overnight Nasa engineers are concerned they might have broken off during the launch and affected the fragile heat protection tiles.

29 After several missions that worked with acceptable levels of erosion on the O-rings NASA waived the requirements for the O-rings. They continually expanded the bounds of risk Conditions are within the margin of safety. They applied all the usual rules in a situation where the usual rules didn t apply. We made a grievous error. Flawed thinking It didn t hurt me yesterday. It won t hurt me today.

30 O-rings.28 inches in diameter

31 With Challenger, an O-ring that should not have eroded at all eroded on earlier shuttle launches. Yet managers felt that because it had previously eroded by no more than 30%, this was not a hazard as there was "a factor of three safety margin". The Thiokol engineer most experienced with the O-rings, pleaded with management repeatedly to cancel or reschedule the launch. He raised concerns that the unusually low temperatures would stiffen the O-rings, preventing a complete seal during flexing of the rocket motor segments, which was exactly what happened on the fatal flight. Challenger's O-rings eroded completely through as predicted, resulting in the complete destruction of the spacecraft and the loss of all seven astronauts.

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33 Space Shuttle Columbia February 1, 2003.

34 Director of Mission Operations told another Nasa official before Columbia's destruction: You know, there is nothing we can do about damage to the TPS [Thermal Protection System]. If it has been damaged it's probably better not to know. I think the crew would rather not know. Don't you think it would be better for them to have a happy successful flight and die unexpectedly during entry than to stay on orbit, knowing that there was nothing to be done, until the air ran out?

35 The Columbia was destroyed because of damaged thermal protection from foam debris that broke off from the external tank during ascent. The foam had not been designed or expected to break off, but had been observed in the past to do so without incident. The original shuttle operational specification said the orbiter thermal protection tiles were not designed to withstand any debris hits at all. Over time NASA managers gradually accepted more tile damage, similar to how O-ring damage was accepted. The Columbia Accident Investigation Board called this tendency the "normalization of deviance" a gradual acceptance of events outside the design tolerances of the craft simply because they had not been catastrophic to date.

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38 DeLung International Inspire. Transfor m. Kurt Braatz Senior Consultant Jim DeLung DeLung