Key Text Slides from GOSH 2017 Oct 31

Safety Fundamentals: Guard yourself against ‘normalization of deviance’. Embrace responsibility, ownership, and accountability. Be

Normalization of Deviance Diane Vaughan, ‘The Challenger Launch Decision’ Getting away with short-cutting safety

PRESSURES: JOB PRESSURES FAMILY WORRIES RELATIONSHIP ISSUES FINANCIAL CONCERNS HEALTH CONCERNS FATIGUE Power. Point

Normalizing deviance leads to… …predictable surprises. …your worst nightmare. injuries and fatalities. Power. Point

Challenger was a pressure driven predictable surprise Power. Point Copyright 2016 by Astronaut R.

Recovered boosters from 12 or 24 missions revealed hot gas O-ring impingement /erosion. 1981….

Criticality Category: 1 Failure Effects Summary: Loss of mission, vehicle, and crew… Power. Point

Schedule Pressure Conflicting Performance Results Margin ‘Mission Accomplished’ Syndrome Communication Failure Power. Point Copyright

Normalization of Deviance Lesson Summary 1. Maintain a sense of vulnerability. 2. Procedural compliance

Responsibility – Ownership - Accountability Power. Point Copyright 2016 by Astronaut R. Mike Mullane

Accountability Lesson Summary 1. See something; say something; do something. 2. Be situationally aware.

COURAGEOUS SELF-LEADERSHIP Continuous Self-Improvement Power. Point Copyright 2016 by Astronaut R. Mike Mullane

Courageous Self-Leadership Lesson Summary 1. We’re better than we think. 2. Tenacity counts BIG!

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Safety Fundamentals: Guard yourself against ‘normalization of deviance’. Embrace responsibility, ownership, and accountability. Be a courageous self-leader. Power. Point Copyright 2016 by Astronaut R. Mike Mullane

Normalization of Deviance Diane Vaughan, ‘The Challenger Launch Decision’ Getting away with short-cutting safety best practices until that ‘deviance’ becomes your ‘norm’. Power. Point Copyright 2016 by Astronaut R. Mike Mullane

Normalization of Deviance Lesson Summary 1. Maintain a sense of vulnerability. 2. Procedural compliance should be a religion. 3. Risk has no memory. 4. Set challenging but attainable goals. 5. Daily mission success reflects your heroism. Power. Point Copyright 2016 by Astronaut R. Mike Mullane

Accountability Lesson Summary 1. See something; say something; do something. 2. Be situationally aware. Have a questioning attitude. 3. We’re all in this together. Take each others’ backs. 4. You count. 5. Leaders: ensure your people ‘count’. 6. Accountability comes with responsibility. Own it to the ‘good’.

Courageous Self-Leadership Lesson Summary 1. We’re better than we think. 2. Tenacity counts BIG! 3. It’s never ‘game over’ when it comes to safety.

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