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The Normalization of Deviance

I remember flying with Jason, a very experienced pilot, and I noticed he followed a checklist before takeoff, he followed a checklist during takeoff, another checklist once we reached altitude, then another series of checklists for landing. When I asked him why he still meticulously followed a checklist, even though he was so experienced that he would be classified as “unconsciously competent," I’ll never forget his answer. He told me, “Because I don’t trust myself.”

I was so confused. How does someone with that kind of experience not trust themselves? So when I asked him to explain he said that when you believe you no longer need the checklist, you fall into something called the “normalization of deviance.” You become so confident and haven’t experienced a failure for skipping a step, that skipping a step here and there becomes normal. Maybe you even begin skipping the most important step of all—using the checklist.

To illustrate that, he pointed at another plane on the tarmac, a Gulfstream 550. He said that he was in Boston a couple of years ago and met a couple of pilots who flew a G550. They had so many hours of flight time under their belts, they were unconsciously competent pilots. They knew what they were doing and were very confident in that. The next day, he saw a notification from the NTSB that a G550 ran off the end of the runway at Boston Logan and crashed, killing sixteen people including the two pilots, the pilots he’d met the day before.

When they reviewed the black box data, they heard the pilots frantically trying to unlock the controls. By the time they decided to shut it down, it was too late. You see, the controls are always locked when the plane is being towed, so that the towing vehicle has complete control. One of the first items in every pilot’s checklist is to unlock the controls.

Up until that point, one or the other of the two had always done it, but this time neither did. Because they weren’t following a checklist, they didn’t realize no one had unlocked the controls. The cost of failure was death for the pilots and their passengers, but it also cost their families and loved ones dearly. They will feel that loss for the rest of their lives, and it could have all been prevented by simply following a checklist.

In a Command and Control organization, the team members don’t understand the why behind the checklist, which means they don’t fully understand the cost of failure. All they know is they were given this checklist and trusted to follow it.

In a Trust and Inspire organization, they’re educated with the EDGE Method, so they fully understand the why behind the checklist as well as the cost of failure. They are self-motivated to follow the checklist not out of self-preservation (fear of being fired) but because they know WHY they’re following it in the first place. They understand that every item on that checklist is there to protect them and their reputation.

A friend was telling me once about how his dad taught him to swim: he threw him in the water and trusted him to figure it out. That’s an extreme example of Command and Control but it’s also a good one. It was literally sink or swim. Tell-Trust-Hope-you-don’t-fail-because-you-might-die.

There is a scene in the show Lessons in Chemistry on Apple TV that illustrates the opposite. A man was teaching a woman (a coworker and his eventual girlfriend) how to swim. He told her that the first step was learning to breathe correctly, so he showed her how to blow bubbles. She was very nervous around water and was too scared to blow bubbles. He asked her if it would be okay for him to kiss her, so they could blow bubbles together, and she said yes. As he kissed her, they went underwater and blew bubbles together.

Now, that’s a very intimate example, but think about it. He told her the first step to learning how to swim was learning to breathe correctly (Educate, Explain), then he blew bubbles underwater (Demonstrate). When she struggled to repeat blowing bubbles, he kissed her and they blew bubbles together (Guide). It was the EDGE Method and it worked. She was afraid to do it by herself after the Demonstrate phase, because she needed a guide to help her be more confident. She didn’t have to do it alone. Another aspect to point out is that he asked her permission to guide her. It’s vital that the person we’re guiding wants to be guided and is open to our help.

Ultimately, the biggest difference between a Command and Control organization and a Trust and Inspire organization is really understanding the true cost of failure, something we’re going to delve into next.

I’ll leave you with this: according to Stephen Covey’s book Trust and Inspire, 92 percent of companies are still operating under Command and Control principles, which means only 8 percent of companies are truly Trust and Inspire organizations. Contrast that with the fact that the vast majority of leaders believe they have a culture of Trust and Inspire. That is a large number of leaders who lack awareness.

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