The normalization of deviance
The explosion of the Challenger space shuttle on January 28, 1986, is generally remembered as having been caused by the failure of a rubber O-ring designed to seal joints on the shuttle’s solid rocket booster.
In The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA, sociologist Diane Vaughan, professor of sociology and international and public affairs at Columbia University, challenged the theory that the disaster was simply a technological failure coupled with a failure of middle level management, as suggested by an investigatory Presidential Commission. While the technology and management did indeed fail, Vaughan probed deeper into the political and managerial culture of NASA to offer a richer understanding of why, in the face of overwhelming evidence that it was extremely risky to do so, the agency made the fateful decision to launch the Challenger.1
Vaughan explored organizational rather than individual misconduct and found answers in the theory of “normalization of deviance” as it pertained to a culture of production and structural secrecy at NASA.2 “Normalization of deviance” refers to a gradual process through which unacceptable practices or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization. Individuals who challenge the norm – from within the organization or outside it – are considered nuisances or even threats.
In the case of NASA, engineers had known since 1977 that the O-rings had a design flaw, but they didn’t believe the rings were susceptible to damage. When they learned otherwise, they made a fix, but the O-rings continued to sustain damage during each subsequent launch. Vaughan’s interpretation is that this history “portrays an incremental descent into poor judgment. It was typified by a pattern in which signals of potential danger – information that the booster joints were not operating as predicted – were repeatedly normalized in engineering risk assessments prior to 1986.”3
Flying the space vehicle with the defective part became the norm, and there were no grave consequences until that cold day in January 1986 when the Challenger lifted off with a seven-member crew that included New Hampshire schoolteacher Christa McAuliffe. Seventy-three seconds later, the space craft violently broke apart and disintegrated in a cloud of smoke as family members at the scene and school children across the country looked on in horror.4
With similarly catastrophic results, Massey Energy engaged in a process of “normalization of deviance” that, in the push to produce coal, made allowances for a faulty ventilation system, inadequate rock-dusting and poorly maintained equipment. The pre-shift, on-shift examination system – devised with the intention of identifying problems and addressing them before they became disasters – was a failure.
Most objective observers would find it unacceptable for workers to slog through neck-deep water or be subjected to constant tinkering with the ventilation system – their very lifeline in an underground mine. Practices such as these can only exist in a workplace where the deviant has become normal, and evidence suggests that a great number of deviant practices became normalized at the Upper Big Branch mine.
These are some examples:
Lack of Air. Extremely low airflow was a chronic problem in some parts of the mine. It became part of the routine of miners and section bosses on Headgate 22 to “go get some air” by closing airlock doors or hanging curtain. In the months leading up to the disaster, the airflow was reversed on a number of occasions. An outsider would consider such a situation as indicative of a serious problem with the mine’s engineering and ventilation plan. At UBB, low airflow became part of the standard operating procedure.
Illegal ventilation changes. Evidence was uncovered of major ventilation changes being made while miners were working underground, a blatant disregard for worker safety and a violation of law. Again, such a practice became the norm at UBB.
Engineering issues. The Upper Big Branch mine lacked an effective engineering design. Rather than having an overall engineering plan to guide the mining, testimony suggested the mine was engineered as operations advanced. To the outsider, this would seem like a backwards way of operating. The engineers, working for Massey’s Route 3 Engineering, were based at the Route 3 office of the UBB mine site about one mile from the North and South portals, and evidence suggests that they frequently were not involved with ventilation changes made by upper management at the mine. Of the engineers who offered testimony to investigators, one said he traveled underground at UBB only once every couple of years;5 one said he had very little involvement with the UBB mine;6 one had never been underground at UBB.7
Water problems. Upper Big Branch had continual problems with high water. In addition to compromising the ventilation system, the high water posed safety risks for workers. Nevertheless, sending men – particularly very young, inexperienced workers – into chest-deep water appeared to be viewed not as a hazard, but as just another job that had to be performed. An outsider would see the potential for a miner breaking an ankle or incurring some other type of major injury because he/she was unable to see the unstable floor surface under the water.
Lack of Safety Equipment. Miners, including those working to pump water out of the mine, were placed in hazardous conditions deep in the mine with no communication, no vehicles, no gas detectors and only one way in and out. Sending miners into remote parts of the mine without basic safety equipment can only be seen as a deviance that poses substantial threat to life and well-being.
Inadequate Rock Dusting. Although rock dusting has long been recognized as one of the most basic elements of safe mining – a major factor in preventing flare-ups from turning into major explosions – dusting was not a priority at UBB. The company’s indifference to rock dusting was evidenced by the fact that only a two-man crew was assigned to dust the entire mine on a part-time basis, and the rock dusting equipment assigned to them did not work properly. As a result, it was not surprising that tests conducted after the explosion revealed inadequate dusting and return entries that were completely black.
Ineffective fireboss system. The preshift, onshift examination process, aimed at identifying problems and protecting miners’ lives, was irrevocably broken at UBB. Although both state and federal inspectors wrote citations for ventilation violations, fireboss records in many cases failed to reveal when and where inadequate ventilation was found. It was acceptable at this mine to do nothing because identifying unsafe conditions might have meant dedicating manhours to correcting the problems. In other instances, when firebosses recorded the need to clean up high levels of coal dust, there is no record that the problems were addressed.
The inference drawn is that it did not matter whether or not a fireboss did his/her job, thus negating one level of safety at the mine. In fact, in the ten days leading up to the disaster, only eleven percent of the rock dustings requested were completed.
Fraudulent fireboss practices. In the weeks preceding the disaster, investigators found that one UBB foreman’s hand-held methane detector had not been turned on, even though he filled in examiner’s books as if he had taken gas readings. This foreman was responsible for assessing gas and water levels in the critical entries adjacent to the longwall panel and reporting conditions leading to the Bandytown fan. Data downloaded from methane detectors indicated that devices used by other foreman also had not been turned on at times when the foremen were underground and responsible for identifying hazardous conditions.
Not only is the failure to take these required readings a violation of state and federal law, it demonstrates an utter failure to understand the purposes of the examinations and their life-or-death consequences. Moreover, it suggests a profoundly dangerous attitude that firebossing a mine is just another burden imposed by MSHA and the WVMHST. A section foreman’s failure to perform them diligently and honestly reflects poorly on the attitudes up the company’s chain of command. If the mine foreman, superintendents or other top officials communicated no sense of urgency about examiners’ work, and if they failed to take care of hazards that diligent firebosses reported, some examiners may come to the conclusion that their assignment is not really that important in a mine fixated on production. Their concept of what is important is delivered through messages such as “get those water pumps repaired,” “get those pumps set,” we need to “get it in the coal.” It may be lost on them that their work is vital to protect their fellow miners’ lives – that pumps keep the water levels low, so the air can flow and the mine does not blow up.
Faulty equipment and structure. From a poorly maintained top of the line shearer to broken rock dusters and damaged and defective airlock doors, an inattention to equipment and structure was the norm at this mine. MSHA testing of the shearer found water sprays missing or clogged. Additionally, MSHA found worn bits on the machine, which exposed steel shafts that increased the danger of sparking when the bits hit rock. The water lines on the longwall were inadequate to supply water to the shearer needed to suppress fire, as revealed by MSHA testing on Dec. 20, 2010. Mantrips, the vehicles that transport workers, were in terrible condition, as evidenced by violations written by MSHA during the investigation. The main track haulage was not maintained from the North Portal to Ellis Switch, and, as a result, MSHA wrote numerous post-explosion violations and orders. Apparently, failure to maintain equipment and structure was not considered a safety issue that had the potential to cause harm if not addressed.
Airlock doors versus overcasts. The company often installed airlock doors rather than constructing permanent overcasts to direct airflow. By one count, there were 12 sets of airlock doors from the North Portal to the longwall.8 Many UBB employees and state and federal inspectors testified that they had never seen so many doors as they saw at UBB. The doors are cheaper and can be installed much more quickly than overcasts, which is probably the reason the choice was made to use doors. There are, however, a number of downsides to using doors rather than building block overcasts. One is that the doors are vulnerable to damage within days of installation if they are struck by heavy equipment moving through them. The doors also can be compromised by human error if accidentally left open by workers. And, perhaps most importantly, it is almost impossible to make them truly airtight. It can only be concluded that use of doors was a relatively inexpensive shortcut taken to address ventilation issues, but most certainly not the best choice for the safety of workers.
Safety mechanisms disabled. Testimony suggested that methane detectors on equipment had been “bridged out,” or disabled, so that production could continue without taking time to make repairs. Although equipment disabling has not been directly tied to the explosion itself, this practice is a present and constant danger to workers and a violation of state and federal law.
In addition to inattention to basic safety standards, Massey exhibited a corporate mentality that placed the drive to produce above worker safety. Miner after miner testified about the pressure to produce coal, and some said directly that Massey’s safety program, Safety One (S-1) took a back seat to Production Two (P-2). These are some of the ways in which this culture of production over safety manifested itself:
Production reports every 30 minutes. The frequent callouts on longwall production were relayed up the Massey management chain to the headquarters of Massey Energy. This reporting, coupled with downtime reports of when and why coal was not being run, sent a chilling message to workers about what management considered most important. In instances in which a section boss did halt production because of a dangerous condition, such as wholly inadequate ventilation, he was instructed to write only “downtime.” He was not to create a record acknowledging a potentially deadly situation.
Injury reports. A large safety board on the outside of the bathhouse at UBB listed reportable injuries with a space available to include the injured worker’s name. Such a public display of this type of information can generate peer pressure and intimidate workers, causing them to fail to report the seriousness of injuries for fear of retaliation.
Institutional secrecy. Workers at UBB were treated in a “need to know” manner. They were not apprised of conditions in parts of the mine where they did not work. Only a privileged few knew what was going on throughout Upper Big Branch. Miners, and even section foremen were not informed about ventilation changes so that many were not even aware of how the air was supposed to travel.
Violations part of doing business. Massey Energy officials have made public statements expressing the opinion that both the number of violations issued against the company and the severity of those violations are part of the cost of mining coal. Information obtained from MSHA’s data retrieval site provides evidence that Massey engaged in a consistent practice of contesting violations and tying up the regulatory process. Between 2000 and 2009, MSHA proposed $1,974,548 in penalties for violations at the UBB mine. To date, the company has paid just $657,905.58, or 33.3 percent, of those proposed penalties. Fighting the violations allowed Massey to pay only a third of the assessed penalties over a ten-year period while accelerating profits, thus negating the punitive intent of the fines.
At the same time, the company has maintained an ongoing public relations campaign in which officials put forward the notion that their mines exceed industry standards for workplace safety. Although this assertion is not true, it is widely believed to be factual by workers, especially those who have never worked for other mining companies.
Intimidation of workers. There is ample evidence through testimony that miners were discouraged from stopping production for safety reasons. Workers said that those who questioned safety conditions were told to get on with production. An example is Headgate 22 foreman Dean Jones, whose wife said he told her he received a “get it in the coal” message from Chris Blanchard through the dispatcher when Jones shut down his section because of lack of air.
In another instance, Tailgate 22 foreman Brian “Hammer” Collins described what happened when he stopped his crew from running coal because he found inadequate ventilation when he did his pre-shift exam. Collins didn’t allow any work to start on his section until the ventilation problems were resolved – a process that took about an hour. When he came to work the next day, he said Performance Coal Vice President Jason Whitehead suspended him for three days for “poor work performance.” Collins stood his ground. “I am hard-headed…I said, ‘No, if I ain’t got the air in my last open break, I cannot load [coal].’”9 Collins should have been commended for attempting to change the culture.
“Nasty Notes.” Miners also mentioned disrespectful written messages they received from Performance Coal President Chris Blanchard. They called them “nasty notes.” “Anybody that bosses for Chris Blanchard will tell you the same thing,” said Glenn Ullman, a miner with six years experience with Massey. If a crew didn’t complete a job during a shift, a nasty note would be waiting on the next shift, “some sarcastic note for all my men to see … [you’d] feel belittled,” Ullman said.10 Some firebosses and foremen said in interviews they were going to “run coal right,” and didn’t care if they were fired for it. Others, Ullman said, were intimidated by Blanchard’s “nasty notes” and didn’t say anything because they were “job-scared.”11
Other mine managers also left notes for crew foremen in assignment books. “Finish up on move. We need to be running in the morning. The very first thing.” “Orders from Chris. It must be running by 7:00 a.m.” “Tell your guys extra effort is needed in order to be off Saturday. Hammer down.”12
Enhanced Employment Agreements. The company also used “enhanced employment agreements” to discourage workers from complaining about safety concerns or working conditions. Under terms of the agreements, the company offered pay increases, bonuses and guaranteed employment in exchange for employees’ agreeing to work for a three-year period. However, by accepting the company’s terms, the miners became “at will” workers. If they left voluntarily or if their employment was terminated “for lack of performance as determined by management, unacceptable conduct … or a serious safety infraction,” the miners had to return the “enhanced pay” and all of the bonuses received under the contract. They also could not work at any competitor’s coal mine within a 90-mile radius of the mine where they had worked.13
The enhanced pay is subject to statutory deductions and withholdings, including state and federal income taxes, and Social Security and Medicare. Even if an employee banked 100 percent of the enhanced pay, he would not have enough to buy out his contract because the net take-home pay from the bonus would always be less than the gross amount of the enhanced pay he is obligated to pay back. The miner would have to delve into personal savings to make up the difference or face being sued and having to pay a financial penalty. In effect, the enhanced employment agreement effectively handcuffs the employee.
A third area in which the normalization of deviance can be observed is a management system that fosters an “us against them” mentality. Some ways in which this could be seen:
An enemies list. Massey appeared to cast as enemies not only regulators and inspectors, but also politicians who failed to blindly support the company and community residents who questioned whether some coal practices negatively impacted their health or well-being. Such an “us against them” attitude can poison the political process, impose a chill on free speech and have a detrimental effect on safety in the workplace.
Employees as members. The designation of employees as “members” suggests “we are Massey in this together” and helps create the cultural dynamic at work within the company. If everyone associated with the company is in this together, then management concerns and worker concerns are one. Veteran miner Stanley Stewart referred to a “Massey code of silence” in which workers kept their mouths shut in order to “be a member.”14 Some miners even affixed stickers to their hard hats saying, “I support Massey Energy 2010.” Investigators observed one sticker that said, “Not Guilty.” Those who violate the membership agreement, who are disloyal to the company by complaining about work conditions or calling hotlines to report safety issues, place themselves on the outside of the club.
Too big to be regulated. As the largest coal producer in the Appalachian region at the time of the disaster, Massey Energy used the leverage of the jobs it provided to attempt to control West Virginia’s political system. Through that control, the company challenged federal and state oversight agencies, including MSHA, the Environmental Protection Agency and the West Virginia Office of Miners’ Health, Safety and Training. Many politicians were afraid to challenge Massey’s supremacy because of the company’s superb ongoing public relations campaign and because CEO Don Blankenship was willing to spend vast amounts of money to influence elections. In one well-documented instance, he used his resources to elect a relatively obscure judge to the state Supreme Court, a plot so intriguing that the author John Grisham borrowed it for one of his best-selling novels. If politicians live in fear of a company, it isn’t a stretch to assume that workers also are fearful. If their elected officials depend on the corporation for campaign funds, there is no one to whom the miners can turn to make sure their workplace is safe.
MSHA made us do it. When deviant mining practices led to the terrible tragedy of April 5, 2010, the company response was to go on the offensive against the federal regulatory agency. The message was direct: MSHA made us change the mine’s ventilation system in ways that were dangerous. This position assumes that the government runs the company. Just the opposite is true. The ventilation system is the responsibility of the operator, and the operator is aware of this responsibility. MSHA’s responsibility is to review the system to ensure that it complies with all safety regulations. These regulations represent the bare minimum degree of protection for workers. If Massey officials believe they are being pressured to run their mining operations in an unsafe manner, the company has the option of stopping production.
Illegitimacy of Regulators. Massey rhetoric challenged the very legitimacy of safety inspectors. The company maintained that their operations exceeded safety standards. The implied “therefore” is that they don’t need those guys telling them what to do. Several miners testified that the company had postings in big letters on the bulletin board at UBB stating that MSHA penalties at the mine exceeded a million dollars. Some miners even wore stickers on their hats with a dollar amount intended to represent how much it cost Massey when the longwall was down. The not-so-subtle message to employees is that MSHA is costing the company money – and workers shouldn’t aid in that process. In an organization where deviance is not the norm, the same information might be used to deliver a very different message, “We have some very serious safety problems at this mine, so much so that we’ve racked up a million dollars in penalties. If you see unsafe conditions, be sure to bring them to our attention. Your safety is our most important concern.”
At the end of the GIIP’s investigation, the evidence leads to the conclusion that the explosion at the Upper Big Branch mine occurred when a spark from the shearer ignited an explosive accumulation of methane, causing a fireball. The fireball in turn ignited coal dust that had been allowed to build up, and the coal dust carried the explosion throughout more than two miles of the mine. Like the O-ring failure on the Challenger, this explanation describes the systems failures that occurred at UBB. It does not answer the deeper question asked by family members and loved ones, “Why did this happen?”
Many systems created to safeguard miners had to break down in order for an explosion of this magnitude to occur. The ventilation system had to be inadequate; there had to be a huge buildup of coal dust to carry the explosion; there had to be inadequate rock dusting so that the explosiveness of the coal dust would not be diluted; there had to be a failure to maintain machinery; there had to be a breakdown in the fireboss system through which unsafe conditions are identified and corrected. Any of these failures would have been problematic. Together they created a perfect storm within the Upper Big Branch mine, an accident waiting to happen.
Such total and catastrophic systemic failures can only be explained in the context of a culture in which wrongdoing became acceptable, where deviation became the norm. In such a culture it was acceptable to mine coal with insufficient air; with buildups of coal dust; with inadequate rock dust. The same culture allowed Massey Energy to use its resources to create a false public image to mislead the public, community leaders and investors – the perception that the company exceeded industry safety standards. And it became acceptable to cast agencies designed to protect miners as enemies and to make life difficult for miners who tried to address safety. It is only in the context of a culture bent on production at the expense of safety that these obvious deviations from decades of known safety practices make sense.
Failure to address the effect of normalization of deviance in any examination of the Upper Big Branch disaster would not only be a disservice to the families, friends and loved ones of the men who died on April 5, 2010. It also would be a disservice to current and future coal miners whose lives depend on this nation’s willingness to ensure safe mining practices.
1 Vaughan D., The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA. Chicago: The University of Chicago Press, 1996.
5 Raymond Brainard testimony, Oct. 26, 2010
6 Heath Lilly testimony, Sept. 15, 2010
7 Matthew Walker testimony, Sept. 9, 2010
8 Brian Collins testimony, p. 30
9 Brian Collins testimony, p. 17
10 Glenn Ullman testimony, p .49
11 Glenn Ullman testimony, p. 48
12 Notebook for J. Burghduff, October 2009
13 Outlined in memorandum from Jason Bussey, Human Resource Manager to Stanley Stewart, “Enhanced Agreements,” December 14, 2007
14 Stanley Stewart testimony, June 5, 2010, p. 185