The normalization of deviance

This is an outstanding read about the normalization of deviancy. It mostly talks about in the aerospace world, but this applies anywhere. He touches on the 2014 Gulfstream crash in Boston, where the crew had made it routine to skip checklists, and tried to takeoff with the gust lock engaged.

He goes on to talk about NASA, and how it was found that after Columbia, they were reverting back to the Challenger days, and pushing to meet schedules and not miss windows, and ignoring the lessons they had learned.

He ends by talking about his own experience, where he almost crashed a Tornado, which would have resulted in both him and his backseater being killed. They were on an exercise, and their aircraft began having gear problems. The only way to get them to lock up was to perform a porpoise maneuver on takeoff, and raise them as they had a 0 G load on the airframe. On the day they departed for home, they weren't able to get altitude, or the nose above 30 degrees while attempting the maneuver. This resulted in them finally recovering, barely, at about 250 feet. They were outside the ejection envelope so if they hadn't recovered, they would have had to ride it in.

The article highlights why it's important to take the time to do checklists, and double check, and not allow yourself to become complacent with not following the rules. In aviation that will kill you faster than almost anything else.

The normalization of deviance.

This is a result of human's nature to find the shortest route to completion - whatever the risks, in fact I believe this nature skews our perception of risk.

Competency is where the problem lies, not necessarily within the incompetent either... The cycle which produces the deviancy is as follows:

We begin (in reference to our task) unconsciously incompetent - we do not know about the task and therefore we do not know we cannot do it.

We then discover the task and become consciously incompetent - but from this comes the need to learn and train.

So after learning and training we become consciously competent - we are fully trained and fully aware of the task we are carrying out. We are diligent and follow each step. We know the whole procedure.

However over time we become complacent, relaxed, we gain confidence in our ability and our conscientiousness drops, it is here we become unconsciously competent - almost equally as hazardous as carrying out the task without competency this stage in the competency circle is where people skip steps, become autonomous and make mistakes.
Source - Noel Birch 1970.

EDIT - To add, this scares the crap out of me when we talk about pilots becoming unconsciously competent!

a reply to: and14263

It scares the # out of a lot of people. That's why articles like this one are so important, as is passing on lessons from accidents and incidents.

a reply to: Zaphod58

I smell what you're cooking, When It comes to overseeing a project there is no margin for error.

If you are an structural engineer, you triple check the girders. If you are a oncologist, you triple check for a misdiagnosis and so forth. I imagine it's even harder for test pilots.

a reply to: Thecakeisalie

Even just regular pilots. The Gulfstream crash that was mentioned could have been prevented with a simple flight control check on the taxiway. Simply moving the control column around would have told them something wasn't right.

The previous five flights the crew hadn't run the checklist, which included a flight control check, at all. More than that, it was normal for pilots of the company they flew for to do the same thing, and skip them.

Pilots, no matter how experienced they are, should live by the checklists. But we're seeing more and more deviation from normal procedures. I just read tonight about an accident in 1986 that killed most of the people on a Soviet airliner. They crashed on landing because the pilot made a bet with the copilot that he could land without looking at the ground and had the flight engineer pull a curtain, blocking his view.

Its in the training...Train train train in the right way to do things..Self discipline and having the inner strength to speak up when things arent going right...

a reply to: Blackfinger

Not always. The reply by and14263 hit the nail on the head. There comes a point where you've been flying for awhile, and nothing has happened so you get more and more confident in your abilities. Then one day, you shortcut a checklist because you're a little late. Nothing happens, so you start to do it regularly. The more nothing happens, the more it reinforces that it's ok to shortcut, even though it isn't.

a reply to: Zaphod58

I get a 404 when following your link.

a reply to: DupontDeux

Should be fixed now.

a reply to: Zaphod58

a lot of feilds suffer from " normalisation of deviance "

and i have personally seen some truely deviant behaviour treated as utterly normal

all to often - its only when these an inquest or other external inqury into a death or major incident - does the full depth of the problem emerge

It's mind-numbing when you hear instances of how complacency has reared its ugly head and taken lives.

We actually got complacent on my second deployment with regards to landing on the carrier in daytime. It was so routine, that we basically stopped briefing it.

I can't find the memo, but I used to teach a module about how a Marine Corps helicopter squadron, operating in Iraq, during hostilities had grown so complacent that the CO wrote a HazRep explaining how him and his staff had to consciously shake up the operations of his command in order to avoid complacency related deaths. He made a statement that blew me away. It went something like "The biggest threat to our unit is Hostile fire, followed closely by complacency" or something similar to that.

He went so far as to break up aircrew pairings, change the flight schedule timing, give "pop quizzes" on systems and threats, and also, to have periodic safety standdown days.

Imagine that happening in a regional airline.

originally posted by: Zaphod58
a reply to: DupontDeux

Should be fixed now.

It is - thanks, I'll have a read.

I also used this guy's concept of organizational drift, which is what it sounds like happened in NASA.

www.safetymattersblog.com...

The concept is that, an organization starts with a safety culture, let's say that means a culture of following checklists. After some time, with no negative consequences, someone departs from using the checklist and nothing bad happens. The confirmation bias forms from the lack of something bad happening, so they do the action again. When/If management finds out about this behavior, if they don't immediately address it, it becomes an approved practice.

So now, NOT following checklists becomes the new approved culture. This process is what Dekker calls Drift. We used the Alaska Air flight 261 crash to prove this point. The inspection and lube cycle on the jackscrew that failed had been pushed way beyond the engineered limits. And all the regulatory bodies and responsible parties thought that it was just fine.

So now, every time I hop on an airline flight, I kiss my ass goodbye.

a reply to: Zaphod58

Not only with aircraft, show of hands, how many people actually do a 'walk around' their car before driving it?

a reply to: Zaphod58

Shortcuts become habits, habits become part of the "Successful routine", "This is how we do it here", then a cascading problem has you relying on your sloppy new habit rather than the proper discipline and tragedies happen.

It is a terrifying thing that happens more than you would think.

a reply to: intrptr

about 2% of the time.

a reply to: Zaphod58

I often find myself getting complacent in my day job, though not to the extent of that Hanscom Gulfstream crash (which was just about in my childhood backyard), but I'll be damned if I ever find myself getting complacent behind the yoke.

It's one thing to bend the rules with patients when you know you can get yourself out of any corners you back yourself into. It's a completely different animal when it's your own hide that's on the line and the consequences are varying shades of "dead". I like life too much to be complacent.

This is my mission ,I swear....great to read a thread titled that.....

It started I guess when flying cancelled checks to Austin...the IRS and banks....my buddy in the capatains seat on the Beech Travelaire would catch some sleep on the two hour leg back to Waco. He went off to Continental and I quit flyimg....the creature comfort at altitude and the friggin schedule....it's as if the airline pilots should get paid twice what they do.....and mainly

Someone should certify fitness for duty or allow them time to sleep 9 hours or so.....commuter pilots for sure huh....you know what's the next sentence....i don't want to spell it out.....a long flight in the wee hours of the morning....two in the cabin.....one is probably sleepy....done with coffee.....as long as only one of the drivers does it....can't write it out....but when we hear a flight went 40 minutes past it's destination, it's not because the pilots were having a heated discussion of the new company policy

then like Zaph posted ....this extends into all our doings and I see it getting worse

Zaph mentioned self discipline.....nailed it....but we could help their self scheduling by lending awareness and action of what kind i don't know...........best thread subject for these days

a reply to: GBP/JPY

That's what alarms on your phone are for

a reply to: Zaphod58

The fact that people so normal as to be prone to making stupid errors of this sort, are ever left in charge of either maintaining or flying an aircraft, is absolutely terrifying.

Shoddy programming is what that is. Too much patriotism, too little professionalism.