Normalization of deviance

Hacker15e said:
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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What you have written here is EXACTLY the point of the statement "Normalization of Deviance". These are not cases of a rogue pilot "doing his own thing".

What NASA discovered after Challenger was that the standard(s) in effect at the time of the accident WERE followed during the launch. The "deviation" was that as leaks were detected in previous launches, decision were made as to the level of acceptable loss rate, and a new standard was established. These became policy and printed in the launch criteria book(s). Not until after the accident were the previous "standards" reviewed and found to be such a departure from the current.
 
Hacker15e said:
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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Well, let's be honest, calling "the boss" at 2:30am to get permission to fly with a logo-light inoperative...well, that's silly - the systems need to be designed intelligently. If you build a system like that, guys are going to ignore instances of it, which leads to more and more ignoring...
 
ppragman said:
Well, let's be honest, calling "the boss" at 2:30am to get permission to fly with a logo-light inoperative...well, that's silly - the systems need to be designed intelligently. If you build a system like that, guys are going to ignore instances of it, which leads to more and more ignoring...
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If the CP gets called enough, he'll work on changing the system. He's the one in charge, so I'd be calling him every time as per policy.
 
ppragman said:
Well, let's be honest, calling "the boss" at 2:30am to get permission to fly with a logo-light inoperative...well, that's silly - the systems need to be designed intelligently. If you build a system like that, guys are going to ignore instances of it, which leads to more and more ignoring...
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It's not designed for singular items covered in other areas. It's for operational related stuff such as overall mission risk.

Still, sometimes it works as intended, sometimes not.
 
MikeD said:
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.
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No doubt, and very true. But these were things almost 30 years ago. One would like to think that in this day and age of 2016, in the US the major Part 121 carriers have really honed and perfected (as close as one can use that word) SOPs. And most of these SOPs came after a disaster resulted with injuries and/or fatalities. The airlines have also tied things together in normal operating procedures. For example, the flight control check then leads me to do a specific flow, upon the completion of which leads (triggers) the PF to do their last mandatory mini-takeoff briefing (which is basically confirming things in the glass), which in turn leads to the before takeoff checklist to the line. If I didn't do the flight control check (for example) the rest of my whole operation would fall apart. Coming up on a decade in the 121 flying industry (which isn't much admittedly) but I have never ever had a CA refuse to run a checklist or not want a checklist done. Some have forgotten in the sense that they were busy with something, etc, but a cue from my side and they always asked for the checklists. I have yet to meet a guy who just outright says "no checklists here" and tries to do a flight. This sort of individual behavior would be very very short-lived. Now compare that to private and corporate jet owners, and how many of them have a checklist discipline as the 121 airlines do? I will give you quite a few accidents as a "can happen to anyone" but not this Bedford Gulfstream crash. That's just waaay too much lack of discipline in both seats.
 
Cherokee_Cruiser said:
I will give you quite a few accidents as a "can happen to anyone" but not this Bedford Gulfstream crash. That's just waaay too much lack of discipline in both seats.
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The "can happen to anyone" doesn't mean a Bedford for everyone. The degrees of severity of what the breakdowns are, the number of them, how they manage to not get fixed, etc; can all vary from operation to operation, and can get worse over time, or better if mitigated. Sometimes that's caught in-house and corrected, sometimes that requires FAA intervention such as with the Delta case. Sometimes it leads to an accident or more, sometimes it's just bunch of minor incidents, and sometimes its nothing more than one of the aforementioned waiting to happen.

So when I say "could happen to anyone", that's the direction I'm coming from. The varying degrees, and where they lead.

The Delta case was in a time when CRM had already made its inroads into 121 cockpits. It's not that delta pilots were unprofessional or bad pilots; but somewhere, a lacksadasical attitude had worked its way into the Delta cockpits, reinforced or allowed to continue by a standards/check/training process which had the same issues. Was essentially a building snowball that was beginning to manifest itself in several high profile incidents noted in my original post above. Once a pause/reset/redirect was able to be noted from the FAA and implemented by Delta, and the ship's course altered to the proper waters, so to speak, then we have the Delta that we have today and the great operation it is.

These things often start insidiously, and work their way into operations slowly and quietly, becoming "new norms", unless caught early or highlighted in an accident. Luckily, we're doing much better than before, constantly improving, but some areas will always need more improvement than others, and the areas needing improvement won't always be the same ones.
 
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Cherokee_Cruiser said:
No doubt, and very true. But these were things almost 30 years ago. One would like to think that in this day and age of 2016, in the US the major Part 121 carriers have really honed and perfected (as close as one can use that word) SOPs. And most of these SOPs came after a disaster resulted with injuries and/or fatalities. The airlines have also tied things together in normal operating procedures. For example, the flight control check then leads me to do a specific flow, upon the completion of which leads (triggers) the PF to do their last mandatory mini-takeoff briefing (which is basically confirming things in the glass), which in turn leads to the before takeoff checklist to the line. If I didn't do the flight control check (for example) the rest of my whole operation would fall apart. Coming up on a decade in the 121 flying industry (which isn't much admittedly) but I have never ever had a CA refuse to run a checklist or not want a checklist done. Some have forgotten in the sense that they were busy with something, etc, but a cue from my side and they always asked for the checklists. I have yet to meet a guy who just outright says "no checklists here" and tries to do a flight. This sort of individual behavior would be very very short-lived. Now compare that to private and corporate jet owners, and how many of them have a checklist discipline as the 121 airlines do? I will give you quite a few accidents as a "can happen to anyone" but not this Bedford Gulfstream crash. That's just waaay too much lack of discipline in both seats.
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I had a captain last year who didn't want to run checklists. We had a non-normal, and he didn't want the QRH either. Granted, that's off the reservation behavior not normalization of deviation, but it does happen.

As someone who has managed two LOSA reports, procedural drift still happens. Sometimes the results aren't flattering. SOPs still need tweaking. The data from safety programs shows the way, and changes are made.
 
Mike Mullane has a couple excellent presentations on this topic. We used one at Commutair to cover normalization of deviance with regards to effective CRM ("Countdown to Teamwork"?) and I gave a different one ("Stopping Normalization of Deviance"? I can't remember the exact titles) to my safety manager to incorporate into her tech training. Both are outstanding.
 
I understand the concept of "normalization of deviance" and that hindsight is 20/20, but as I read the article I kept trying to understand the "go" mentality given they were participating in an exercise, not a life-and-death wartime mission. Are there not different risk tolerances for training/exercises vs live-ammo missions?
 
Normalization of deviance, christ that sounds like the area i worked at in ZAU. If you looked at our LOAs/SOPs and watched how we really operated you would think that they were 2 different places.
 
exneophyte said:
I understand the concept of "normalization of deviance" and that hindsight is 20/20, but as I read the article I kept trying to understand the "go" mentality given they were participating in an exercise, not a life-and-death wartime mission. Are there not different risk tolerances for training/exercises vs live-ammo missions?
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Of course there are.

You also have to realize, though, that the mantra "train like you fight" is the combat derivative of the law of primacy. We want to train fighter pilots in peacetime to do the right thing when the iron starts getting shot at them in combat.

Combat pilots spend entire careers in a mission-accomplishment-focused mentality. "Good airmanship" in the military fighter flying world (the "fast jet" community, as they call it in the Commonwealth nations) has to do with figuring out how to accomplish a goal first, and then balancing out risk second. In order to build that combat ORM skill, you have to practice it during the years of peacetime training that maybe lead up to doing it in combat. You can't just default to the most safe answer during years of peacetime training, and then suddenly flip a switch on night 1 of the war and start making different decisions.

Sometimes pilots lose focus of the fact that training is just training, and push tactical scenarios into decisions that aren't the most conservative or safe answer.
 
milleR said:
Mike Mullane has a couple excellent presentations on this topic. We used one at Commutair to cover normalization of deviance with regards to effective CRM ("Countdown to Teamwork"?) and I gave a different one ("Stopping Normalization of Deviance"? I can't remember the exact titles) to my safety manager to incorporate into her tech training. Both are outstanding.
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Are these presentations company-internal kinds of things, or can they be shared? I'd love to see them.
 
For the "there's no way this could happen to me" and "this can only be an isolated issue, the rest of us are professionals" crowd:

http://www.insurancejournal.com/news/national/2016/09/29/427689.htm
Corporate Pilots Often Neglect Required Safety Checks
Corporate pilots routinely take off without performing required safety checks, a study of thousands of flights by a trade group has found.

Prompted by the 2014 crash of a corporate jet that killed billionaire Lewis Katz, which occurred after pilots neglected to ensure their flight controls worked, the National Business Aviation Association discovered that similar lapses are common.

The group representing corporate flight departments reviewed data from almost 144,000 flights during three years and found that in more than 25,000 cases, or 17.7 percent, pilots failed to complete the same routine check of a plane’s flight controls that doomed Katz and six others on the plane.
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For reference, here's 50 pages of "those guys were idiots, we would never do that":
http://forums.jetcareers.com/threads/g-iv-down-in-ma.200819/

EDIT: Here's the source article from Bloomberg with slightly different content:

http://www.bloomberg.com/news/artic...found-to-skip-safety-check-on-17-7-of-flights
 
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Hacker15e said:
For the "there's no way this could happen to me" and "this can only be an isolated issue, the rest of us are professionals" crowd:

http://www.insurancejournal.com/news/national/2016/09/29/427689.htm


For reference, here's 50 pages of "those guys were idiots, we would never do that":
http://forums.jetcareers.com/threads/g-iv-down-in-ma.200819/

EDIT: Here's the source article from Bloomberg with slightly different content:

http://www.bloomberg.com/news/artic...found-to-skip-safety-check-on-17-7-of-flights
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Not going through the 50 pages again, but I thought the topic was corporate vs. airline world for the "wouldn't happen to me" crowd for the flight control check.

In the airline world, very frequently the flight control check is preceded by something, and is then a trigger for something else that needs to be done (a certain flow). And only after that backed up with a checklist. 121 is very disciplined, and will get a chewing on a line check/recurrent sim event if checklists or flight controls aren't used/checked.

In the corporate world, unless it's a large organized department that mirrors 121, I think it can be an entirely different animal. I have heard many horror stories from guys at the current shop from their ex-corporate jobs in the many years before.
 
My assertion is that it does not matter who you are or where you work, if you are a pilot, you are susceptible to a normalization of deviance.

The worst part, IMHO, is the "it can't happen to me" hazardous attitude. Direct, verbatim from the list of FAA's hazardous attitudes...and yet still people cling to it.

The posts from @PhilosopherPilot about his experiences in the training department at a major carrier and from @MikeD about the histories at Delta and Continental should blow a nice, ragged hole through the idea that the 121 airlines are magically immune to it.

The whole point of acknowledging it is having the self awareness that you and your shop, your airplane, your crew, your flight, your leg could fall into the trap, so as to help you avoid it.
 
Hacker15e said:
My assertion is that it does not matter who you are or where you work, if you are a pilot, you are susceptible to a normalization of deviance.

The worst part, IMHO, is the "it can't happen to me" hazardous attitude. Direct, verbatim from the list of FAA's hazardous attitudes...and yet still people cling to it.

The posts from @PhilosopherPilot about his experiences in the training department at a major carrier and from @MikeD about the histories at Delta and Continental should blow a nice, ragged hole through the idea that the 121 airlines are magically immune to it.

The whole point of acknowledging it is having the self awareness that you and your shop, your airplane, your crew, your flight, your leg could fall into the trap, so as to help you avoid it.
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No one is immune to normalization of deviance. But we take a risk-assessment approach and use safety measures like LOSA (which is pretty huge) and make changes based on observations. Line checks and sim checks also help reinforce SOP and try to squash the deviance.

Problem is much more so in a corporate department (especially with only 2-8 pilots) in which there may very well not be any LOSA/FOQA/safety program to do a self-check of their operation.

No one is immune, but at least the airlines try and constantly do something about deviance from normal operations.
 
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