We’ve always done it that way, how could this happen?


Incidents often occur at organizations, where the root cause is found to be “human error”. In other words, a procedure was not followed properly or was otherwise ignored. Chances are it’s not the first time this procedure was broken. So how does this happen?  We have an answer to this question and suggestions for leaders who want to avoid this issue.

When something abnormal happens over and over again, without a negative consequence, people don’t recognize it as abnormal anymore. We call that normalization of deviance.  It can have a devastating ripple effect. In order to stop the ripple, we must understand how it is born.

Normalization of deviance doesn’t happen overnight. It is a very slow process that happens in different phases.

Phase 1. Parameters happen outside of normal without negative consequences. – An employee decides they don’t need to follow the procedures. They know the procedures, but just decide, “it’s easier this way.” Maybe they save time, maybe they’re lazy. Who knows…

Phase 2. Nothing negative happens as a result of this parameter breach and previous limits are ignored. – This same employee continues to do work in a manner inconsistent with established procedures. Nothing negative happens. They are sure the supervisor saw them do this, as well as others in the department. They are never challenged.

Phase 3. Deviations continue without issue, moving further away from the original intended target. – Now this employee, with silent consent, continues to deviate further from the procedure. They even begin changing other procedures, since nothing bad ever happens. They are now training other people to do things in similar manners. Everyone is happy with the result, because nothing bad ever happens.

Phase 4. Event happens. – After a couple of months of being lulled into a false sense of security by results and lackluster inspections or follow-up, a major event occurs. Everybody wonders, how in the world could this happen? No one ever saw this coming. Nothing bad ever happened in this dept. before.

How do we counter this? We must live with a 3D mindset and normalize excellence.

Detail – Fine tune our thoughts to the details of the task at hand. Ensure that employees understand the “why” behind the procedure. Empower the workforce and give them a way to make documented changes to procedures. Have a process for reviewing procedures at some frequency.

Diligence – Constant and earnest effort to accomplish what is undertaken – persistence. Continuous follow up by leaders at all levels to ensure outcomes are being realized in the proper environment. Just because nothing bad happens, doesn’t mean we are following the process. Behavioral studies, like peer-to-peer reviews are very effective ways to ensure results are in accord with goals.

Discipline – This isn’t referring to punitive discipline, but discipline exhibited by the suppression of base desires. It is synonymous with restraint, self-control and consistency. Discipline is characterized by a strong dedication to repeatedly doing what’s right. Instill this attribute into the culture of the organization.

In what other ways can leaders “normalize excellence”?