The Drift That Destroys
“The beginning of wisdom is to call things by their proper name.” — Confucius
The most dangerous failures don’t begin with a bang.
They begin with a shrug.
A checklist skipped because “we’re short-staffed.”
A torque spec ignored because “we’re already behind schedule.”
A warning dismissed with “we’ve done it this way before a million times.”
And then — nothing happens.
No explosion. No critical audit finding. No customer complaint.
So we do it again.
And again.
And again.
Until one day, the corner that’s been cut becomes the weakest link.
That small deviation that once saved time now invites failure.
The team, often stretched thin and running blind, can’t react fast enough — not because they don’t care, but because there is no margin for error.
And what was once a silent drift becomes a very loud reckoning.
We act shocked. We ask how it occurred when we are so careful, citing the a dusty binder or excel file filled with SOPs. We seek to find those to blame.
But the truth is, the system didn’t break overnight — it drifted.
Quietly. Gradually. Predictably.
And we allowed it to occur on our watch.
This phenomenon has a name: Normalization of Deviance.
Coined by sociologist Diane Vaughan in her study of the 1986 NASA Challenger disaster, it describes the slow, collective process by which small rule-breaking is ignored or permitted until it becomes standard behavior. What starts as a one-time exception becomes tolerated, then routine — until disaster exposes how far we’ve wandered from the original standard.
This isn’t just a problem at NASA or Boeing.
It’s in your plant, your warehouse, your hospital, your office. Perhaps, your home.
It’s in any system where people feel pressure to deliver more than they’re resourced to do — and where leaders turn a blind eye to how it gets done, so long as the numbers look good.
The question is not whether your organization will face stress.
The question is whether the shortcuts you’ve normalized will hold up — or snap — when put to the test.
The Drift Is Real — And It’s Everywhere
Normalization of deviance isn’t limited to rockets or aerospace. In healthcare, medication protocols are sometimes bypassed due to clunky software or staffing shortages. In construction, site inspections get rushed to meet client deadlines. In manufacturing, preventive maintenance slips because “we’ll get to it next quarter.”
A study by the Joint Commission found that more than 60% of adverse events in hospitals involved deviations from standard procedures — most of them known, but tolerated. OSHA reports similar patterns in industrial incidents: the hazards were documented, but workers had grown used to ignoring them.
This is how entire systems drift into dysfunction: slowly, quietly, and with plausible deniability. It becomes the culture.
“That’s just how it’s done around here.”
Until one day, this ad hoc, workaround system fails.
Boeing and the Price of Drift
The Boeing 737 MAX tragedies were not caused by one decision, but thousands of small, cumulative ones. Pressure to cut costs and accelerate production on the part of leadership led to a quiet erosion of standards. Tribal knowledge walked out the door as veteran engineers were bought out or let go to cut costs. Frontline concerns often were ignored. Documentation gaps began to widen. Feedback loops, never robust in most organizations already, begin to collapse.
And yet, nothing happened — at first.
Planes rolled out.
Metrics looked good.
Dashboards shone green.
Until two planes fell from the sky.
Following a complete investigation, the official reports laid it bare: warnings were downplayed, internal dissent was muffled, and speed was prioritized over safety.
This, from a company that once represented the gold standard in aviation.
Normalization of deviance isn’t an accident. It’s a pattern. And at Boeing, that pattern was actively being ignored.
“We warned Boeing that it was going to lose a mountain of expertise,” said Ray Goforth, executive director of the union representing Boeing engineers. “But the company blew us off.”
What began as exceptions quietly hardened into routine.
Voices from the front line were filtered at first, then softened, then ignored.
By the time leadership had finally recognized the depth of the drift, the damage was wired into the system.
What Drift Feels Like
Maria, a lead tech at Boeing with 15 years on the line, remembers when inspections were sacred. “Now?” she shrugs. “We’re told to skip them unless we’re being audited.”
She’s not angry. She’s worn down by the slow, steady corrosion of standards that no one at the top seemed to notice, or worse, chose to ignore. Over time, that silence became the policy. And in its place grew a culture where drift was tolerated, then baked in to the recipe. It doesn’t just burn out individuals — it breaks the system from the inside out.
It’s not just her. Across industries, workers are being asked to improvise while pretending that standards still exist. They are told to own the outcome — but not given the tools to influence the inputs.
That’s not empowerment. That’s systemic gaslighting.
Standards Are Not Bureaucracy. They Are Protection.
W. Edwards Deming, the pioneer of modern quality management, is best known for transforming postwar Japanese industry and advocating that sustainable excellence comes from improving systems — not blaming people.
Deming taught that standards, done right, are not red tape — they are a form of respect. Standards protect people. They reduce variation. They ensure continuity and remove ambiguity in a complex system. When leadership’s main focus is on short-term efficiency, standards are often the first thing to erode.
If a worker is asked to “just get it done,” even when a tool is missing or a checklist isn’t followed, that’s not empowerment. That’s abandonment.
At Toyota, leaders are taught that poor system flow is not just a technical failure — it’s a moral one. It disrespects the worker by forcing them to absorb the undue friction, take unnecessary risk, and do confusing, unnecessary work. A broken process is not the worker’s burden to overcome — it’s leadership’s duty to fix.
When companies fail to reinforce clear, human-scale processes, they invite fragility into their operations. It doesn’t always show up in quarterly reports. But it lurks. And when the system is stressed — by a surge in demand, a critical failure of a part during production, or a loss of key personnel — that fragility turns to chaos.
The Deming Counterweight
Deming never believed that you could shame or threaten your way to excellence. He believed that quality is built into the system — not inspected in after the fact. And he believed that dignity at work wasn’t just a moral imperative, but a strategic one.
“A bad system will beat a good person every time.”
In today’s landscape, many leaders still treat performance problems as personal failings. But when you zoom out, you see the truth: the system is driving behavior. And right now, that system is, too often, built around rewarding deviance from standards.
Good companies design systems that hold the line on standards. Great companies build systems that evolve — but fix them when those systems begin to erode.
Guardrails for Greatness
Normalization of deviance doesn’t announce itself with alarms. It seeps in through shortcuts in processes, unclear or changing expectations, and vague direction from leaders — until dysfunction begins to feel like efficiency.
Preventing that drift isn’t about drafting more work rules. It’s about cultivating a system that makes the right way the easy way — what Toyota teaches its leaders is the highest form of respect for workers. If the system doesn’t flow, the failure isn’t on the frontline. It’s on leadership.
It means building a culture that prizes integrity over expedience, where the value of doing something right is embedded in daily work — not just posters on the wall.
It means rewarding people for surfacing problems, not for hiding them. It means designing systems where adherence to standards is possible under pressure, not something workers have to figure out how to fit into the schedule. It means recognizing that real craftsmanship comes not from compliance, but from pride — and pride only thrives where people are supported, not squeezed.
This kind of culture doesn’t emerge by accident. It is built deliberately, patiently, and with a clear-eyed commitment to excellence that doesn’t compromise when the line backs up or the quarter runs short. It shifts the view to pride in workmanship. Here’s what that looks like in practice:
Protect tribal knowledge. Don’t just replace senior staff — capture what they know. Their deep understanding of how the work really gets done is invaluable. Pair them with newer employees to pass on system memory. Interview them, document their insights, and treat their experience like the operational asset it is. If you wait until they walk out the door, you’ve already lost too much.
Elevate frontline signals. Treat deviations from standard and near misses as gold mines for improvement, not nuisances to suppress. Dig into root cause.
Reinforce standards daily — not as punishments, but as the foundation of craftsmanship. Ensure frontline leaders deeply understand the processes they oversee and how the work should be done. Teach supervisors to lead by observing with humility and managing with respect.
Tie metrics to meaning. If your system rewards only speed or cost reduction, you’ll get drift. Balance output with integrity.
Slow down when it matters. Speed is not a virtue if it erodes your margins for safety, quality, or resilience. If defects rise faster than output, you’re not scaling — you’re spiraling.
Audit your standards. If they’re not being followed, ask why. If they no longer serve, improve them — don’t abandon them. Don’t tolerate uncontrolled variation in process — because it mathematically guarantees uncontrolled variation in output.
Tell deviance stories. Normalize talking about mistakes — not with blame, but with curiosity. Use structured methods like Root Cause Analysis (RCA) or the Five Whys to uncover how systems, not individuals, created the conditions for failure. This isn’t about finger-pointing. It’s about learning. The goal is not just to correct the error, but to prevent its recurrence — and to foster a culture where people feel safe surfacing problems early, before they compound.
Honor good friction. When a worker slows the line to flag a safety concern or refuses a shortcut that compromises quality, that’s not resistance — it’s integrity. In healthy systems, that kind of friction isn’t punished; it’s prized. Celebrate the people who raise uncomfortable truths, who protect the standard when it would be easier to bend it. Their courage is your early warning system — and your best defense against disaster.
The Positive Path Forward
Normalization of deviance isn’t inevitable. It’s not a failing of character — it’s a failing of culture. But culture can be changed.
It begins when leaders stop treating standards as obstacles and start honoring them as agreements. When doing the right thing is easier than cutting corners. When raising a concern is seen not as insubordination, but as stewardship.
Systems that respect their people don’t require perfection — they require clarity, consistency, and care. They understand that pride in craft is not born from pressure, but from purpose. From being part of something that holds the line because the line matters.
This isn’t about nostalgia for how things used to be. It’s about the hard, hopeful work of building systems that endure — not by pushing people harder, but by designing with them in mind.
Because excellence isn’t a result of squeezing more. It’s the reward of refusing to drift.
And in that refusal — that daily discipline to do it right — we recover something deeper than efficiency.
We recover trust. We recover dignity. We recover meaning.
And that’s the kind of system worth building.
Author’s Note
This piece comes from two decades of watching systems drift — sometimes slowly, sometimes all at once — and seeing good people pay the price. I’ve worked inside plants where standards were sacred and others where they were optional. The difference wasn’t intelligence or capability. It was leadership. Culture. Courage.
Normalization of deviance doesn’t start with bad actors. It starts with good people under pressure. It spreads when silence feels safer than truth. And it calcifies when leaders stop listening.
This essay is not about blame. It’s about responsibility — the kind that starts at the top but belongs to all of us. I write this for the operators who’ve seen shortcuts become policy. For the leaders who want to do better but feel trapped by the urgent. And for anyone who still believes that dignity and discipline aren’t opposites — they’re allies.
You don’t have to be perfect. But you are required to notice.
—Todd Andrew Owings
Sources:
Diane Vaughan and the Challenger Disaster
Vaughan, D. (1996). The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA. University of Chicago Press. Vaughan introduced the term “normalization of deviance” in her analysis of how systemic drift contributed to the Challenger explosion.Boeing and Normalization of Deviance
Kitroeff, N., Gelles, D., & Nicas, J. (2019). “‘Shortcuts Everywhere’: How Boeing Favored Speed Over Quality.” The New York Times.
https://www.nytimes.com/2019/12/15/business/boeing-737-max-crashes.htmlFrontline Expertise Ignored at Boeing
Flight Safety Foundation. (2020). “Normalization of Deviance.” AeroSafety World, Feb. 2020.
https://flightsafety.org/asw-article/normalization-of-deviance/Joint Commission Report on Deviations in Healthcare
The Joint Commission. (2018). “Sentinel Event Data – Root Causes by Event Type.”
Over 60% of adverse healthcare events involved known but tolerated deviations from procedure.OSHA Data on Workplace Incidents
Occupational Safety and Health Administration (OSHA). (2022). “Commonly Cited OSHA Standards.”
Many citations involve known violations that were habitually overlooked on-site.Deming on Systems and Respect for People
Deming, W. Edwards. (1986). Out of the Crisis. MIT Center for Advanced Educational Services.
Famous for the quote: “A bad system will beat a good person every time.”Toyota’s Leadership Philosophy
Liker, J. K. (2004). The Toyota Way: 14 Management Principles from the World’s Greatest Manufacturer. McGraw-Hill.
Toyota emphasizes that poor flow is a sign of disrespect for workers — it signals a system failure, not a people failure.Root Cause Analysis and Systemic Learning
National Patient Safety Foundation. (2016). RCA2: Improving Root Cause Analyses and Actions to Prevent Harm. RCA isn’t about blame — it’s about learning and redesigning systems to prevent repeat failures.Hidden Costs of Speed Over Quality
Spear, S. & Bowen, H. K. (1999). “Decoding the DNA of the Toyota Production System.” Harvard Business Review.
Demonstrates how chasing speed without maintaining process discipline leads to long-term inefficiencies and quality issues.The Human Toll of Cultural Drift
Field observations and interviews from U.S. operations and manufacturing environments across healthcare, logistics, and industrial sectors over the past 20 years.