The Weekly Reflektion 43/2025
Normalisation of deviance is a subject that has graced many of our Reflektions and it remains a major factor in creating the circumstances that lead to disasters. People become familiar with the hazards around them until they are no longer uncomfortable. Poor procedures are followed blindly, or procedures are not followed properly, and since there are no immediate consequences, people continue with their ‘familiar’ routines. Then one day the circumstances are different and just doing what we did yesterday and the day before is not good enough. When it all goes wrong, sometimes it is just an irritation, sometimes someone gets hurt and sometimes people die. One thing we know from experience is that the consequences once the mistake is made are often unexpected, although probably predictable.
Is your organisation becoming too familiar with the risks?
Many of Aesops fables involve a lion and a fox. The lion symbolizes power and strength, and the fox, wisdom and cunning. The morals from the stories are often related to the triumph of wisdom over power, a key risk management principle. In the story of the Fox and the Sick Lion, an aging lion spreads a rumour that he is old and sick and is on death’s door. The rumour includes a suggestion that the lion regrets all the animals he has eaten over the years. He asks all his ‘friends’ to visit him in his den so that he can show this regret, apologize for all the trouble he has caused, and say farewell. Once the rumour becomes well established, the animals start to believe that the lion really is sick. One by one, they visit the lion to hear his confession and bid him farewell. One by one they are eaten, and the lion enjoys a convenient delivery service for his meals. One day the fox turns up at the entrance to the lion’s den to pay his respects. The lion invites him in; however, the fox is reluctant and notes that the lion doesn’t seem so sick now. Not unsurprising given the hearty meals the lion has been enjoying recently. The fox also observes that there are many footprints into the den and no footprints coming out. ‘Get well soon’, said the fox and quickly runs away.
Once something becomes familiar, for example, ‘the lion is sick’, it is often mistaken for the truth. Even though there is experience that the dangers associated with the lion can lead to unfortunate consequences, the new familiar situation leads to complacency and precautions are neglected and the risk increases.
The leaking ‘O’ rings on previous successful space shuttle launches made it difficult to prevent the launch of Challenger on 28th January 1986. Even though the engineers were concerned due to the predicted low ambient temperatures their concerns were not enough.
Ignoring safety rules and procedures had become common place at the Chernobyl nuclear power station, without any major consequences. These came on 26th April, also in 1986.
The captain of KLM flight 4805 was mainly working on simulator training where communication with the flight control tower is standardized and always gives clearance when required. He interpreted an ambiguous statement from the controller as confirmation that he could take off. The Tenerife airport disaster 27th March 1977 was the tragic result of this familiarity.
We need to be foxes. We cannot afford to mistake familiarity with the truth. We should not believe that just because we didn’t have an accident yesterday is a guarantee that we will not have one today.