Normalization of deviance

I think this is a good article; as many of you on JC know, I have experienced this myself during my military career. When I say "it could happen to any of us" (as I have more than a couple times here on JC when we talk about these kinds of accidents) my statements are usually met with a fusillade of "no way, it can't be me".

I've been in situations with highly-trained, highly-skilled pilots in units with high standards of rule-following and a compliance mindset (some of us in the Air Force call this the "church of Flight Discipline"), and even in that environment I saw -- and participated myself in -- normalization of deviance.

The article states it well when it says,
This is because it is difficult for someone outside of these small units to have gained the experience and knowledge from within and so incredibly hard to understand if what the unit is doing is, indeed, ‘normal’.
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Yet again, I say: it could happen to any of us. In my opinion, anyone who says it can't happen to them just hasn't been in the correct set of circumstances to see it. I know a lot of extremely good aviators -- both military and civilian (including 121 airline pilots) -- who have also experienced this, and didn't believe it could happen to them, either. I sure as heck wouldn't have believed it could happen to me.

For me, personally, having seen it myself and having been sucked into it very insidiously, I am a much better and smarter aviator because of the self-awareness of knowng that I've been susceptible to it given the right circumstances. This is s topic I'm actually very passionate about because of that.
 
Normalization of deviance is something they talked to us about during our two day course on CRM/TEM before Indoc. It's a really fascinating subject, and most importantly I'm glad I've learned about it so I can recognize it in day to day ops and be a part of the solution rather than the problem by being very careful in everything I do to not deviate to what might seem "easier," or a "that's how everyone does it anyways" mentality. I have seen it happen though, and I see how easily it can suck people in. My certificate, and the lives of the people sitting next to me, behind me and below me are way too important to short cut a step "because everyone else does it." This is one of those jobs where we have to give %110 every minute of every day and not just when we feel like it.
 
I'm fettered by the twin curses of numeracy and logic, but I certainly try to give 90%, at a minimum. And that hasn't always been the case, for all of the reasons alluded to in the original post. Wise words.
 
I've mentioned this here on JC before a few times in the past.
The phrase "Normalization of Deviance" was coined by NASA during their investigation of the Challenger explosion. They discovered that the same O-ring connection had leaked on several launches that spanned years!

It is interesting how quickly we can fall into this if we don't follow the standard.....
 
Hacker15e said:
When I say "it could happen to any of us" (as I have more than a couple times here on JC when we talk about these kinds of accidents) my statements are usually met with a fusillade of "no way, it can't be me".

Yet again, I say: it could happen to any of us. In my opinion, anyone who says it can't happen to them just hasn't been in the correct set of circumstances to see it.
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x2. Agreed.

Lots of things that make you scratch your head in the "why/how?" thought, have happened to guys with far more experience and time than us.

Like the guy in my unit who had a midair, successfully bailed out of the jet, only to slide out of his harness and fall 10,000+ feet to his death upon main canopy deployment because his leg straps had been disconnected.
 
MikeD said:
x2. Agreed.

Lots of things that make you scratch your head in the "why/how?" thought, have happened to guys with far more experience and time than us.

Like the guy in my unit who had a midair, successfully bailed out of the jet, only to slide out of his harness and fall 10,000+ feet to his death upon main canopy deployment because his leg straps had been disconnected.
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Man. I hope something knocked him unconscious as he slid out of the harness.
 
dustoff17 said:
It is interesting how quickly we can fall into this if we don't follow the standard.....
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Although this is true, I think it is vitally important to understand that sometimes it is the standard itself that has slowly evolved and mutated over time and circumstance. Sometimes while operating in the fishbowl, things don't look odd (or in the parlance of this article, "deviant") until you take a step away from the situation and re-assess from a distance. Sometimes it is the eye from outside the organization that re-cages perspective.

For all the guff that Seggy gets for his criticism of Alaska flying, of airshows and demonstration flying, of military flying, etc., I don't just immediately, openly scoff what he says when he notes that he thinks those communities have standards that are too far off the safety ranch. Although much of the time I don't end up agreeing with his perspective, based on my experience I always listen to and consider his perspective as it might just be the canary in the coal mine, indicative of something I haven't yet seen or considered. I'm always willing to reconsider my opinions in light of new evidence.

A pilot can think that they are adhering to the standard with pure intent, and be in a bad situation because it is the accepted standard that is the problem.
 
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Normalization of deviance?

In the airline world though, there are training cycles and line checks to help ensure that any deviance from SOP is corrected and fixed. That's why I have a problem with the Bedford/Hanscom Gulfstream crash when guys say the airline guys shouldn't say it would happen to them. That Gulfstream crew routinely (day in, day out) never did any flight control checks. Something like 97% of the time they didn't. And they skipped checklist + had no good checklist discipline.

In the airline world, any pilot deviating like that would be corrected in a sim or a line check. But more quickly, it would be brought up by the other pilot who would speak up and say he wasn't comfortable just doing things by skipping checklists. My company has a sim event every 6 months. I would like to think that any deviance by a pilot can be caught and fixed in very quick time.
 
Good article - the message, I think, carries over to any kind of flying done by any kind of pilot and I believe the message is "just because it worked last time doesn't mean it will next time or the time after that etc.."

It applies to just about any and all parts of the operation of safely piloting an aircraft from block to block.

Bp244
 
Cherokee_Cruiser said:
Normalization of deviance?

In the airline world though, there are training cycles and line checks to help ensure that any deviance from SOP is corrected and fixed. That's why I have a problem with the Bedford/Hanscom Gulfstream crash when guys say the airline guys shouldn't say it would happen to them. That Gulfstream crew routinely (day in, day out) never did any flight control checks. Something like 97% of the time they didn't. And they skipped checklist + had no good checklist discipline.

In the airline world, any pilot deviating like that would be corrected in a sim or a line check. But more quickly, it would be brought up by the other pilot who would speak up and say he wasn't comfortable just doing things by skipping checklists. My company has a sim event every 6 months. I would like to think that any deviance by a pilot can be caught and fixed in very quick time.
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It still happens. And can even affect the Standards world. The USAF isn't immune......Bud Holland proves that. Neither is 121 flying.

Delta Air Lines got their ops audited by an FAA Special Inspection in the late 1980s (1987), with numerous accidents and incidents occurring in a short timeframe...within about 3 years.

Delta was re-inspected in 1988, and had instituted major changes in the below noted deficiencies by 1989.

- The Delta L-1011 that get about 60 miles off course on the North Atlantic Track, passing just underneath a CAL 747.
- Delta 767 departing LAX where Capt shuts down both engines, luckily restarting them prior to ditching into the Pacific. And then......continuing the flight to CVG.
- Delta jet wrong-airport landing, like has happened to other airlines, mistaking Frankfort Ky for Lexington.
- Delta jet landing on wrong parallel at CVG.
- Delta 191 landing accident DFW
- Delta 1141 takeoff accident DFW (post audit)

In part, the FAA's 1987 special inspection of Delta, which came about due to these incidents occurring in such a short timeframe, found items (at the time) such as "observed instances of a breakdown of communications, a lack of crew coordination, and lapses of discipline in Delta's cockpits." as well as a "...lack of organization, coordination, standardization and discipline in the cockpit that can be attributed to minimal guidance in the flight manuals and a lack of direction from those who develop, supervise and manage flight training and standardization programs"

Also noted by the inspection team were inadequate manuals and procedures, with a recommendation made that "Delta Air Lines study, develop, and publish specific crew duties for each crewmember. These functions should be placed in applicable manuals, and checking phases."

With regards to training, checking and standardization, it was observed that "on numerous occasions on which check airman conducted excessive training during check rides...." and that "Additionally, the 1987 special inspection team report noted that Delta's check airmen were not upholding a high level of standards on proficiency checks," and that "the team observed that orals are in general very brief, questions shallow, and the standard of knowledge low." The FAA Inspection team found documented cases of check airman failing to record unsatisfactory performances by Delta pilots. To the FAA, this constituted a violation of 14 CFR 121.401(c).

It was recommended that better documentation of unsatisfactory performance be maintained, and that "Delta's management needs to give serious consideration to the implications of tolerating minimum standards in training and on proficiency checks."

So basically, no one airline or operation is immune to problems or rough patches in their time. The best airline today, could've had a very rocky time before, and vice versa. Sometimes, the gyros need to be recaged at an organization.
 
Part of the problem with normalization of deviance is that you can get away with a lot of deviance and not have it kill you - except for that one time when it kills you with a quickness. Not only that, but the focus on "getting the job done," pleasing passengers, and efficiency gets combined with the fact that there are objectively bad regulations and flight department policies out there, so guys break one to get the job, don't die, get fired, or violated, so they figure "well one is as good as any other" then they go on and break another, perhaps more critical one. I've seen it 100 times or more, and I've been guilty of it plenty myself.
 
ppragman said:
Part of the problem with normalization of deviance is that you can get away with a lot of deviance and not have it kill you - except for that one time when it kills you with a quickness. Not only that, but the focus on "getting the job done," pleasing passengers, and efficiency gets combined with the fact that there are objectively bad regulations and flight department policies out there, so guys break one to get the job, don't die, get fired, or violated, so they figure "well one is as good as any other" then they go on and break another, perhaps more critical one. I've seen it 100 times or more, and I've been guilty of it plenty myself.
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Years ago, before FOQUA, I was the NFP (non flying pilot) and captain, going into a hub and we just started our descent. I was kind of zoning out, enjoying the view, when the silence was shattered by the over speed clacker. I was then shocked as the FO, rather than pulling back the power and decreasing the descent rate, reach over to the center console and silenced the clacker. "What the *&^% are you doing?", I asked. The FO responded, "Everyone does this. The barber pole is a goal, not a limit." I told him to fix it immediately. We then had a talk about high speed flutter.
The scary thing to me was that the FO found such behavior to be perfectly normal, which meant more than one captain out there used the technique.
 
Blackhawk said:
Years ago, before FOQUA, I was the NFP (non flying pilot) and captain, going into a hub and we just started our descent. I was kind of zoning out, enjoying the view, when the silence was shattered by the over speed clacker. I was then shocked as the FO, rather than pulling back the power and decreasing the descent rate, reach over to the center console and silenced the clacker. "What the *&^% are you doing?", I asked. The FO responded, "Everyone does this. The barber pole is a goal, not a limit." I told him to fix it immediately. We then had a talk about high speed flutter.
The scary thing to me was that the FO found such behavior to be perfectly normal, which meant more than one captain out there used the technique.
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Yep. Hell, I know of guys in the caravan who'd pull the CB for the overspeed horn for exactly that reason: "everyone's doing it, and plus it freaks out the passengers!" My thought was, "well no-S it freaks the passengers out, that loud freaking horn should freak you out." And personally, I tend to fly the King Air up close to barber pole during the descent, but is it smart? Hell, I dunno, as long as it's smooth I suppose and I don't go over, hopefully there hasn't been too much fatigue or overspeeds by guys over the years... As for what other guys do, I'm not so sure, I remember being in the 1900 a several years back about 5 kts under barber pole and having a coworker pass me like I was stopped as we both came in to land. When I asked him about it, he said, "I wasn't going that fast," that was the end of that conversation and I never felt safe in that particular airplane again.

Still though, we have to also realize that some regulations and policies are objectively bad. For example, in the 135 world I think 135.225(a)(1) is an objectively bad regulation that contributes to guys doing unsafe things when much safer alternatives exist. And that's just off the top of my head. Other policies lend themselves to being broken, and thus result in non-compliance - for example, I know of a place that assigns a points based risk assessment score. They have you apply a substantial amount of points for MEL'd equipment - at 2:30 in the morning, you may have to call your boss, wake him up, and ask for permission to fly because the number two transponder is inoperative, or a tail-flood light is inoperative - neither of which being inoperative cause any change on a particular flight. This lends itself to guys simply "ignoring" those provisions of the risk assessment program because it inconveniences a bunch of people, takes time, and has the same result as not participating. You have to develop programs that empower people and lend themselves to compliance, not that simply become a box to check.
 
The Air Force has a similar ORM process that works because the approval authority gets higher up as the risk is ratcheted up.

If you have to wake up the Colonel at an odd hour to get his/her permission to do it, one has to weigh the importance vs the pain-in-the-rectum to get the approval to. That's the whole point.

In my experience in the military, that doesn't lead to ignoring the process, rather it leads to modification of the operations planned. Of course, a lot of that has to do with the compliance culture in the USAF. Mileage may vary in other corners of the aviation world.
 
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