Strategos Lean Briefing

Strategos Lean Briefing

The Newsletter of Lean Manufacturing Strategy

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Challenger Disaster & A3 Problem Solving 

The Normalization of Deviation

Books & Videos

Strategos Guide to Value Stream & Process Mapping

Also...

Guide to Cycle Counting

Warehouse Planning Guide

Human Side of Lean Video

Space Shuttle Challenger exploded on January 28, 1986, the immediate cause was the failure of a joint connecting sections of the Solid Rocket Booster. But underlying this immediate cause were organizational, social and management issues. One such issue was "Normalization of Deviation", a term coined by author and socialogist Diane Vaughan. 

A problem is some deviation from the desired, planned or expected state. Our plants and businesses are rife with such problems. The result can be a catastrophic disaster as with the Space Shuttle Challenger or a slow motion disaster as when a company becomes uncompetitive over years or decades.

Our new web page on the Normalization of Deviation recaps:

  • Some of the history behind Space Shuttle Challenger and its infamous O-rings.
  • Normalization of Deviation as it appeared in the space shuttle program
  • How this same phenomenon appears in business and manufacturing.
  • How A3 Problem Solving might have prevented the Challenger disaster and how it can counteract Normalization of Deviation in other settings.

We can assist you with training or facilitation of your problem solving and process improvement teams. Please call or email me if you would like to talk further.

Best Regards,

Quarterman Lee

816-931-1414

Email Us at Strategos, Inc.

Related Articles

Normalization of Deviation

A3 Problem Solving & Root Cause Analysis

 

Related Training

A3 Problem Solving & Root Cause Analysis

 

Lean Briefing Archive Issues

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