Thinking allowed

thinking_man Was listening to some of my BBC Radio 4 recordings over the weekend, one of my favourite pastimes. I’d considered recording Thinking Allowed for some time but never got round to it. Often I’m a bit pressed for recording slots since my beloved Pure Evoke-3 radio will time the recording of up to 20 programmes and I can easily fill that on my Saturday ritual of going through the TV guide picking out the best of the week’s radio offerings.

Anyway, the programme is on every Wednesday at 16:00, repeated on Mondays at 00:15. I suppose one of the things that put me off listening was the programme description as ‘New research on how society works’. Hmmm… that sounds heavy. But I’m glad I did record it since the very first article had my attention. You can listen to this particular broadcast by clicking here.

This first article was about the disastrous consequences of a drug trial in 2006 and the lessons learned. The contributors then went on to talk about normalisation of deviance. Tricky little phrase, isn’t it. How about the following quotation from Scott Snook which puts it another way:

Each uneventful day that passes reinforces a steadily growing false sense of confidence that everything is all right – that I, we, my group must be OK because the way we did things today resulted in no adverse consequences.

Now I accept this isn’t what you’d normally expect to read on my blog about everyday things. But what caught my attention was the regularity that the root cause of problems is all about normalisation of deviance… or I suppose you could put it more simply as complacency. Nothing went wrong today so everything must be OK. But this complacency effects us all continually at both work and home … and for some the effect is catastrophic.

For example, at present the news is full of the enquiry into Staffordshire Hospital, where its reckoned hundreds of people died at the hands of a hospital whose management put budgets and targets ahead of patient care. Untrained receptionists assessing patients in A&E? Patients being forgotten in corners of wards, left unwashed and untended for weeks? Hard to believe this is an NHS Hospital in the UK subject to external assessment which was failing patients for years. Normalisation of deviance.

One of my jobs in the past has been work measurement and process improvement. Ideal job for someone who’s nosey and a paid up member of the awkward squad, and I suppose that’s why this topic appealed to me. I’ve learned through hard experience that the danger time is when everything seems to be running smoothly. That’s just hiding the faults, and very often it’s the workers on the front line who know the dangers and may well have adopted some avoidance procedures the managers know nothing about.

Put in place a process with checks and balances. And never forget that where human beings are involved, unless you occasionally check things personally it’ll all end up in a heap some time in the future.

Here’s some more examples of extreme failures that are difficult to understand.

TGN1412 Clinical Trial

On 13 March 2006, six healthy young volunteers took part in a clinical trial in which they were injected at ten minute intervals with a drug developed to fight autoimmune disease and leukaemia. Very soon afterwards they became violently ill. One of the two additional volunteers injected with a placebo who showed no ill effects recalled to newspaper reporters: “The men went down like dominoes. They began tearing their shirts off complaining of fever, then some screamed that their heads were going to explode. After that they started fainting, vomiting and writhing around in their beds.” All six suffered multiple organ failure, and were admitted to intensive care.

Prior to the 1980s guidance on such trials was that each injection of a volunteer should be spaced by about an hour to check there was no violent or unexpected reaction before the next volunteer was put at risk. Sounds pretty sensible doesn’t it. For some reason that part of the guidance was dropped and it became the norm to inject volunteers without any safety break.

Challenger Space Shuttle Disaster

The disaster that occurred on 28-Jan-1986 arose from failure of an O-ring seal in the right solid rocket booster. Hard to believe then that immediately prior to the event Thiokol (the contractor) objected to the launch of the shuttle due to abnormally low temperatures and fear of malfunction of the O-ring.

This was a high profile and unique event for NASA… it was scheduled to be the first flight of a new program called TISP, the Teacher In Space Program. The Challenger was scheduled to carry Christa McAuliffe, the first teacher to fly in space having been selected from among more than 11,000 applicants from the education profession.

For years NASA had continued shuttle launches in spite of recurring damage and an inherent defect in the O-rings. And finally in a midnight hour long conference on the eve of the launch with the engine contractors telling them directly NOT to launch in such cold conditions for fear of O-ring failure, NASA management pressures again took precedence over safety.

 Royal Air Force Nimrod XV230

The Nimrod crashed in Afghanistan on 02 Sep 2006 killing 14 military personnel having suffered a leak during midair refuelling, this entering the bomb bay where it caught fire either as the result of an electrical fault or hot air leaking from a heating pipe.

On 23 May 2008 the coroner who led the inquest into the deaths stated that the entire Nimrod fleet had “never been airworthy from the first time it was released to service” and urged that it should be grounded. Assistant deputy coroner for Oxfordshire Andrew Walker added: “This cavalier approach to safety must come to an end. There were failures...[in monitoring the planes' safety]...that should, if the information had been correctly recorded and acted upon, have led to the discovery of this design flaw within the Nimrod fleet”.

At the subsequent review the summary stated “Its production is a story of incompetence, complacency and cynicism.”

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