Sharing my 10 minutes of fame from a number of Safety-First Webinars with hope that there might be something for you to take away at the end that will help make you a safer pilot. Today we will take a look into how a small change in your procedures may seem acceptable at first, but when left unchecked could lead to disaster. Or more simply stated, the normalisation of deviance. This applies to a every one of us. Not only the experienced aviators, rather it is a human factor every one of us should be aware of.
Normalisation of deviance was a term first coined by sociologist Diane Vaughan. When reviewing the Challenger disaster, Vaughan noted that it was the root cause of the incident. It was due to the repeated choice of NASA officials to launch the space shuttle despite a known design flaw. Without going into too much detail, what happened here is the result of 3 critical factors.
1. Pressure: NASA had mandated 24 missions a year. That's one flight every 2 weeks. Setting the bar high. To meet these demands, after each flight, the 1000LBS boosters were recovered, inspected and reused to improve turnaround time. This institutional pressure along with an almost arrogant attitude, led to some questionable decisions being made.
2. Rationalisation: After just the second flight, quality assurance noticed significant deterioration in these O-rings. An intolerable consequence at the time. According to existing SOPs the Fleet should have been grounded immediately. Instead, the team rationalised (after ground testing purposely compromised O-rings under extreme pressure) that a lower standard could be sustained in order to keep up with the 24 mission-a-year mandate. Naturally, we would expect disaster to strike immediately. However, it is the exact opposite that results in a deviance being normalised. And that's…
3. Positive Reinforcement: Instead of immediate catastrophe, everything went well for the next 20 odd missions. With no reason to resolve the issue, this continued acceptance of reduced standards (deviance) became the new standard. Hence a normalisation of deviance. Vaughan describes this phenomenon as occurring when people within an organisation become so insensitive to deviant practice that it no longer feels Normalisation of Deviance wrong.
Insensitivity, occurs gradually and sometimes, over years. Because disaster does not happen until other critical factors line up. NASA reduced their standards after just a few flights, Challenger was the 25th mission. More than a year later.
I'm sure many of you are already aware of this historic event and the valuable lessons learnt. All of us are here today to sharpen the blade and keep the cobwebs at bay. Which is important. Particularly in aviation where safety is such a critical factor. A matter of life and death. I think it's important to remind ourselves of the responsibility we hold when operating in this space.
As aviators, we're all well aware of our human limitations. Normalisation of deviance is no different.
Now how do we mitigate these risks and ensure that we don't pull the wool in front of our eyes and become blind to our own errors? I'd like to briefly discuss four things we can do to help avoid the potentially devastating effects it can have:
1- Recognising One's Own Vulnerability
It's natural human tendency to seek out shortcuts, avoid repetition and save time. Particularly in today's world where everything and everyone is operating at a million miles an hour. Being a human factor, it applies not only in aviation, but to every aspect of our lives. It might be worthwhile asking yourself, where does this idea of normalising deviance have an effect in your day-to-day life?
If you can, I'd like the brave and honest souls out there to comment on one thing that sticks out in your mind where your standards have deteriorated, or habits that you know to be bad have been adopted over the years. One's that are now the new operating standard. It can be anything at all, aviation related or otherwise, as this applies to all industries and every individual.
A while ago I was fortunate enough to tag along on a flying trip to Kariba. One of the conversations we had was on how doing your run-ups while taxiing is a terrible idea. A now accepted standard for one of the crew. Not only are run-up one of the most important checks before flight, it's also a relatively busy and stressful part of the flight. I think everyone would agree that sitting in the holding bay for an extra 10 minutes is the better alternative. Not to mention that when on a fly away in Africa, the bus usually doesn't leave the airfield until the last aircraft has arrived anyway. It just means you might get a head start on the beers. And like normalisation of deviance, this may seem like a win at first, but the long-term loss is almost always evident.
In aviation, hazardous habits can creep up in any number of ways, and it tends to be the experienced ones that fall prey to accepting deviance most. Bearing in mind that normalisation of deviance requires an extended period of time to manifest, or reinforce a new standard. Its only once a pilot steps away from the flight school environment and becomes completely independent, an invincibleChuck-Yaeger-like individual, that bad habits start to creep in. Never think you're too good to make a mistake. And always be willing to learn.
2- Meet the Standards. Always
Remember that your first 150 hours of flying are your safest. Statistically speaking. Where a healthy fear seems to rule most of your decision making. Beyond which, seems to be the tipping point where we begin to relax our safety standards and push our personal limits. Examples of normalisation of deviance here could be, failing to do the necessary checks that now seem frivolous, like testing the brakes before taxiing, or on downwind before landing. Veering away from standard procedures such as ensuring the canopy is locked EVERY time you close it. Or doing your run-ups on the roll.
It's these seemingly small/ allowable deviations that if left unchecked become the new normal/ new standard procedure and in turn fix the first hole (right in the middle) of your slice of Swiss cheese. We know that when enough of these deviations/ holes line up, bad things start to happen.
3- Trust your Instincts & Speak Up
Take the time to listen to that gut feeling. Rekindle that student pilots mentality and concern for, well just about everything. And most importantly speak up if you find yourself in a team environment, or take action when on your own. In multi-crew environments this can manifest in a number of ways. Most commonly, in the form of group think, where no one wants to upset the balance of the group and all opposing perspectives or alternatives are ignored.
Another way could be the deference of responsibility, where the second in command rationalises that the captain must know better, or have a better understanding of the situation, simply because he is the authority. Remember: The power of all teams lies in the individual. Every single perspective count and can make a difference. Never doubt the importance of your unique perspective. Take initiative and speak your mind. A little responsibility and self-leadership could mean the difference between the success or failure of your team/ crew.
4- Learn from Others
Exactly what we are all doing here today. Our ability to learn from others and share experiences is one of the greatest assets we have. We are a social creature, in a world today, that is infinitely connected. With the internet, almost everything is archived and accessible. There are no excuses for us to repeatedly make the same mistakes. It is however, up to us to find the information and educate ourselves. Air Crash Investigation is just one of many sources of well-known aviation incidents and accidents that we can learn from.
These Safety-First webinars are another. And one that I am very glad to have been a part of.
