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COMMENTARY - Normalization of deviance: Is this standard for AF explosives safety?

Bien Hoa mishap illustration

This sketch depicts the flight line configuration of the Bien Hoa mishap that occurred May 16, 1965. (U.S. Air Force photo illustration by Tech. Sgt. Amanda Dick)

SHAW AIR FORCE BASE, S.C. --

I recently heard the term normalization of deviance. Having never heard this term, I began a little research to educate myself and was immediately convinced normalization of deviance has become common practice in the world of explosives safety.

Before I get into that, a little background on normalization of deviance.

President Ronald Reagan appointed former Secretary of State William Rogers to investigate the Challenger 51-L shuttle mishap in 1986. According the Challenger disaster entry on the Encyclopedia Britannica’s website, the Rogers Commission Report was released in June 1986 and faulted NASA and its contractor Morton Thiokol for poor engineering and management, specifically the failure of O-rings that were seals between the lower segments of the right-hand rocket booster.

During the investigation, numerous engineers testified they “had been expressing concern about the reliability of the seals for at least two years and who had warned superiors about a possible failure the night before 51-L was launched.”

Sociologist Diane Vaughan coined the term normalization of deviance while reviewing the Challenger disaster. The article “When Doing Wrong Feels So Right: Normalization of Deviance” points out that, “Vaughn noted the root cause of the Challenger disaster was related to the repeated choice of NASA officials to fly the space shuttle despite a dangerous design flaw with the O-rings”.

In a 2008 interview with Consulting NewsLine, Vaughan said, “Social normalization of deviance means that people within the organization become so accustomed to a deviant behavior that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety.”

This single statement convinced me that normalization of deviance has become common practice in the world of explosives safety. I do believe part of the comfort level, and my perceived normalization of deviance comes from the fact that we have experienced very few catastrophic explosive safety mishaps. Those we have experienced seem to be quickly forgotten.

For example, the Bien Hoa mishap May 16, 1965, killed 27 US service members. The disaster at Bien Hoa Air Base, Vietnam, drove testing and eventually new explosive safety quantity distance rules to ensure we wouldn’t have another disaster the magnitude of Bien Hoa, yet we have airfields that closely match Bien Hoa’s configuration today.

I cannot count how many times someone has asked, “When is the last time something blew up?”

A NASA article titled “The Cost of Silence: Normalization of Deviance and Groupthink” from 2014 points out, “There’s a natural human tendency to rationalize shortcuts under pressure, especially when nothing bad happens. The lack of bad outcomes can reinforce the “rightness” of trusting past success instead of objectively assessing risk.”

I began my explosives safety journey in 2005 and have dealt predominantly with explosives safety in the U.S. Air Forces Central Command area of responsibility for the past eleven years. During my first deployment in explosives safety, I was part of the bed down planning team for B-1s at a new location. We spent weeks presenting courses of action, and eventually, leadership enacted a plan that presented the least amount of explosives risk in the event of a mishap.

It is inevitable in the deployed environment leaders may need to accept an increased risk to personnel, equipment, and assets for many factors, including host nation rules, lack of available space, etc. During planning for the bed down of additional forces in Afghanistan in 2009, the lack of available space was the challenge we faced.

I will never forget, and have passed on to many young explosive safety personnel, the words of our commander at the time, “No is not in your vocabulary. Identify the risks; reduce those that you can; and we will accept the rest.”

In that instance, there were numerous high risks, but the mission demanded the acceptance of those risks.

Air Force Manual 91-201, Explosives Safety Standards, contains specific guidance that explosives safety professionals follow when processing deviations to quantity distance requirements for explosives. The strategic or compelling reason for the deviation, the proposed corrective actions, and the options considered have become the three main victims to the term normalization of deviance.

The previous examples contained numerous strategic and compelling reasons to accept the risks, yet in those cases, we endeavored to mitigate as many risks as possible while simultaneously ensuring mission accomplishment. We have remained at war for decades now, in truth since 1991 if you count the continuous deployments since Operation Desert Storm, I would argue we have become numb to accepting and presenting risks to leaders, and thus, have fallen victim to normalization of deviance.

Do we present and accept risks based on convenience and human nature to take the path of least resistance, the easy way out?

For example, due to lack of available space, a deployed wing decides to use a location for storing outbound cargo that is in violation to quantity distance standards to nearby munitions loaded aircraft. Leadership decides the loss of the outbound cargo is acceptable in the event of an explosives mishap. The loss of the assets will not stop or affect mission accomplishment, so this is a low risk.

Since the same personnel who process and load the outbound cargo on aircraft also process outbound passengers, leadership is advised operations will benefit by having passengers wait in the same location as the cargo. Leaders are now asked to accept the additional risk to personnel.

In this example, in the event of an explosive mishap, all personnel in this location will be killed due to blast overpressure and fragmentation. The strategic or compelling reason for this decision? In all honesty, convenience. Previously, personnel were at a location outside of the explosive clear zone and were a ten-minute bus ride to outbound aircraft.

Remember that question, “When is the last time something blew up?” Well, the other standard question explosives safety professionals get is, “Who is the waiver authority?”

This is definitely not a one-size fits all situation. The previous example is an extreme outlier. I have witnessed many leaders push back, question risks, and force further evaluations along with new courses of action.

Once again, though, human nature is to take the path of least resistance. Ultimately when explosives safety is concerned, a study of previous explosives mishaps may conclude, just as the Challenger mishap did, we have potentially normalized deviance.