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Normalization of Compliance

Psychology

For almost a year after the crash of Gulfstream IV N121JM on May 31, 2014, you couldn't open an aviation magazine or attend a safety symposium without hearing the term, "The Normalization of Deviance." In fact, I am guilty on two counts:

  1. I spoke to an aviation class at Bridgewater State University on the subject, here is a video of that presentation.
  2. I wrote about it for Business & Commercial Aviation Magazine, here is a copy of that.

But here we are, three years later, and it seems we as an industry have already forgotten our promises to fix what is broken.


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Photo: "Double, double check everything," from the movie "The Memphis Belle"

Video: Checklist Discipline.

Many Hollywood movies tell us aviators come from set molds that are drawn from extremes. In "The Memphis Belle," for example, you had a captain who insisted everything be done by the book, even if it had already been done by the book, versus the copilot who believed that once it's done, there is no sense checking it again. The problem with this Hollywood view is that most of us pilots have personalities that include both extremes. We all understand the value of rigid discipline, but we also realize there can be so much of that by the book mentality that you could lose the ability to think for yourself.

By the book or seat of the pants? The truth is most pilots have natural tendencies in both directions.

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Photo: Lockheed X-104 Starfighter with test pilot Tony LeVier, 1955, USAF Photo

You just have to face facts here. You wouldn't be a pilot if you didn't have an ego and if you are a pilot with an ego you think you have invested in your hands a special power that keeps you safe. Something deep inside you believes you are above the rules and regulations meant for weaker pilots. The sane part of you knows that's not true. And it is that sane part of you that must constantly keep that insane part of you in check. Only then can you avoid the normalization of deviance.

The Normalization of Deviance

There is probably no better example in the aviation world of the Normalization of Deviance than the crash of Gulfstream IV N121JM. But the term actually comes from a slightly higher altitude, from the National Aeronautics and Space Administration (NASA). The normalization of deviance can be found way back, perhaps starting with the preflight test of Apollo 1 on 27 January 1967. A spark from a bundle of wires was turned into fire by the pure oxygen in the capsule. That fire was fed by the many flammable materials in the cockpit. Escape was made impossible by a hatch that only opened inward. Astronauts Virgil "Gus" Grissom, Edward White, and Roger Chafee were probably killed in 30 seconds. It took rescuers nearly five minutes to open the hatch. NASA later fixed each of those items (the pure oxygen environment, the flammable materials, and the hatch). The NASA culture that allowed them in the first place, however remained. The term "normalization of deviance" was coined following the 1986 launch of the Space Shuttle Challenger.

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Photo: Challenger explosion, 28 January 1986, from NASA.

Definition

The term "normalization of deviance" was coined by sociology professor Diane Vaughn in her 1996 book, The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA, where she examines the tragedy of the 1986 launch of Space Shuttle Challenger. It is a useful term for us in the business of flying airplanes:

[Vaughn, pg. 58.]

  • Deviance refers to behavior that violates the norms of some group. No behavior is inherently deviant; rather it becomes so in relation to particular norms.
  • Deviance is socially defined: to a large extent, it depends on some questionable activity or quality being noticed by others, who react to it by publicly labeling it as deviant.
  • [In the case of the Space Shuttle Challenger incident], actions that outsiders defined as deviant after the tragedy were not defined as deviant by insiders at the time the actions took place.

NASA and the Infamous O-Rings

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Photo: An earlier launch of the Space Shuttle Challenger, April 4, 1983, (NASA Photo)

The Solid Rocket Boosters (SRBs) on the space shuttle were built by Morton Thiokol, who was quite literally the cheapest bidder. Each booster was 149' long and 12' in diameter, was manufactured in six sections, and delivered to NASA in sets of two which were joined at the factory. The three combined sections were joined in the field. Each joint kept hot propellant gases on the inside with the help of two rubber-like O-rings and an asbestos-filled putty. The 1/4" diameter O-rings surrounded the rocket's entire 12' diameter. The secondary O-ring was meant to be redundant, a safety measure.

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Figure: Solid motor cross section, from Space Shuttle Challenger Accident Report, Volume I, figure 14.

While the overall shuttle program was designed with a temperature range of 31°F to 99°F as a launch criteria, the SRBs were never tested at lower temperatures. In fact, Thiokol stated that O-ring temperatures must be at least 53°F at launch, or they would become brittle and would allow "extreme blow-by" of the gases.

But early on in the program there was evidence of some "blow-by" beyond the primary O-ring. Engineers determined an "acceptable" amount of erosion in the O-ring and for a while these norms held up. Starting in 1984 the amount of damage to the primary O-ring was increasing. Engineers were alarmed but were later convinced the damage was slight enough and the time of exposure was short enough that the risk was acceptable. In 1985 some of the SRBs returned with unprecedented damage, the majority came back with damage, and in one case the secondary O-ring was also damaged. For one launch, there was complete burn through of a primary O-ring. In each case, the decision was to increase the amount of damage deemed acceptable and press on. When it was no longer possible to say the two O-rings were redundant, NASA decided to waive the requirement.

Temperatures on the morning of the launch were well below 53°F. Thiokol engineers recommended delaying the launch but NASA managers applied pressure on Thiokol management, who were unable to convince their engineers to budge. So they elected to make it a "management decision" without the engineers and agreed to the launch. It was 36°F at the moment of launch. The O-rings on one of the field joints failed almost immediately but the leak was plugged by charred matter from the propellant. About a minute after launch a continuous, well-defined plume from the joint cut into the struts holding the SRB to the main tank and the SRB swiveled free. The flame breached the main tank five seconds later which erupted into a ball of flame seconds later. The shuttle cabin remained intact until impact with the ocean, killing all on board.

Much of the reporting after the event focused on the O-rings. After the accident report was published, the focus turned to NASA managers breaking rules under the pressure of an overly aggressive launch schedule. But, as Professor Vaughn points out, they weren't breaking any rules at all. In fact, they were following the rules that allowed launch criteria and other rules to be waived. The amount of acceptable primary O-ring damage went incrementally from none, to a little, to complete burn through. Over the years the practice of reducing safety measures with waivers had become normalized.

Lessons Learned Can Be Temporary: The Space Shuttle Columbia

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Photo: Damage to Space Shuttle Columbia during launch, (NASA Photo)

Seventeen years later, on February 1, 2003, the Space Shuttle Columbia was lost as it reentered the earth's atmosphere. A piece of insulating foam from the external tank broke away and struck the left wing, damaging a heat tile. When Columbia re-entered the earth's atmosphere, the damage allowed hot atmospheric gases to penetrate and destroy the internal wing structure which eventually caused the shuttle to become unstable and break apart, killing all on board. Like the earlier incident, NASA failed to pay heed to engineering concerns about previous incidents of tile damage from separating foam.

Organizational and Personal Failures: The Case of N121JM

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Photo: Gulfstream IV N121JM Wreckage, from NTSB Accident Docket, ERA14MA271, figure 10.

On May 31, 2014, the crew of Gulfstream IV N121JM started their engines without running the engine start checklist and neglected one of the steps which would have them disengage the flight control gust lock. They then skipped the after starting engines checklist which would have required the flight controls to be checked; had they done this, they would have realized the flight controls were locked. They also skipped the taxi and line up checklists, as well as the requirement to check the elevator's freedom of movement at 60 knots. They were unable to set takeoff thrust, realized this, and continued the takeoff. The rest, unfortunately, is history.

As the news gradually leaked out from the NTSB accident investigation, we in the aviation world were stunned. How could two pilots had been so inept? But their airplane was outfitted with a Quality Assurance Recorder and we learned that this type of behavior was the norm for them. For example, the recorder revealed that they had skipped the flight control check on 98% of their previous 175 takeoffs.

More about this: Gulfstream IV N121JM

The Gulfstream IV is a beautiful aircraft and being awarded a GIV type rating has to say something for any pilot. The two pilots who crashed it that day in 2014 had to have been pretty good at some point.

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Photo: Gulfstream IV N121JM, (Photo: Bob Holland)

But something happened to them along the way. It would be hard to go through initial training on this airplane and not have a healthy respect for how complex it is and the need to follow the checklist with some amount of precision. But over the years they stopped following the checklist and stopped having any amount of respect for the airplane. As pilots, they failed. But there is more to it than that.

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Right after the crash I suspected the pilots were trained by the Brand X simulator company but I was wrong. They were trained by FlightSafety International, the best in the business. I've heard people argue that these pilots put on a good act at the simulator so their instructors couldn't detect just how non-compliant they were. I don't buy that. I think any good instructor should have been able to detect this. I think we as an industry have failed the pilots by not providing honest training.

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When I heard this crew had passed their Stage II SMS audit I was also a bit perplexed. I know of auditors out there that are less than scrupulous and I was disappointed that the NTSB didn't dive more deeply into this in their report. A flight evaluation isn't required during an SMS audit and I think that is wrong. But even without a flight evaluation, I thought an SMS auditor should have been able to detect a problem with this pair of pilots. It wasn't until much later that I heard this SMS audit was done over the phone.

The NTSB report also mentions this pair of pilots flew with a fair amount of contract help. Here again I think anyone flying with this pair should have been able to detect a problem. But more than that, I think they should have said something. So in all three of these areas — their recurrent training, their SMS audit, and their exposure to contract pilots — in all three areas we as an industry failed them. We allowed them to deviate from best practices and then we allowed them to normalize that deviance.

Aviator's Definition of the Normalization of Deviance

You won't find this anywhere, I just made it up . . .

The normalization of deviance is the incremental change to standards we once thought inviolate, turning actions once thought to be unacceptable into the new norm. The path to normalizing deviance can be paved by unrealistic standard operating procedures, an unrealistic ego, or by an unwillingness to admit one's vulnerabilities.

Who is Susceptible?

At this point, having seen how two Gulfstream pilots can succumb to the normalization of deviance you may think, "that could never happen to me, I'm better than that." But remember that NASA was filled with highly respected professionals who gave in. Could it happen to you? It certainly happened to me.

Who is Susceptible? I am.

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Photo: Eddie and his T-38, 1979

I was 23 years old when the United States Air Force gave me the keys to a supersonic jet and told me I was good enough to slip the surly bonds of earth and dance the skies on laughter-silvered wings.

Up, up the long delirious burning blue
I've topped the wind-swept heights with easy grace,
Where never lark, or even eagle, flew;
and, while with silent, lifting mind I've trod
the high untrespassed sanctity of space,
put out my hand and touched the face of God."

From "High Flight," by John Gillespie, Jr.

How can a 23 year old not walk away from that without a serious ego? The Air Force mentality back then was you had to have this kind of self assured bravado to survive as a military pilot. So with 182 hours of jet time I was awarded my wings to see if I could survive out there without scaring myself too badly.

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Photo: Eddie in his T-37, 1979

A few years later, while assigned as a KC-135A copilot, I was allowed to fly the T-37B all over the U.S. to build flying time and experience. I got to know that airplane very well and soon found myself flying tighter patterns than the book called for and got a particular joy from flying my overhead patterns inside what most the fighters were doing. Then, one day, I got caught in the wing tip vortices of an F-111 and found myself inverted just a few hundred feet off the ground.

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Photo: Eddie's wings, 1979

Fortunately we recovered, nobody was hurt, no metal was bent. I learned that those wings they pinned on my chest gave me more than the ability to dance on laughter-silvered wings, but the responsibility to use good judgment when doing so. The Air Force mentality has changed since then. Where senior leadership use to turn a blind eye to this kind of conduct as a necessary part of seasoning pilots, they now agree that this is serious business and it ought to be taken seriously.

Who is Susceptible? You are.

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Photo: NASA Mission Control, 30 Aug 2009

Who is susceptible to the normalization of deviation? Let me put it this way. If these guys are, so are you. Any facet of aviation is susceptible because:

  • There is a high level of training required — leading you to believe your preparation trumps all.
  • There is a high level of skill required — leading you to believe you are good enough, even better than those rules requiring checklists and strict procedures.
  • Practitioners of the craft are accorded a high level of respect — leading to an environment where outside criticism is rare.

So YOU are susceptible to the normalization of deviance. Who, exactly, is you?

  • Pilots — the ones with the flight controls in our hands.
  • Flight engineers — the ones with the best view of what is going on in the cockpit.
  • Flight attendants — the ones close enough to the action but removed enough to be objective.
  • Mechanics — an untrained, overworked, or tired mechanic can have as large, if not larger, impact on flight safety than the pilots.
  • Dispatchers and schedulers — The first line of defense against violations of duty rest, flight time limits, validation of airports, facilities, and everything that goes with getting an airplane from Point A to B and back again.
  • Users ("customers," passengers, the "principal," clients, etc.) — the most powerful enablers for or against the normalization of deviance.

You may be wondering why I included "users" in this list of things that have a role to play in the normalization of deviance. Consider this, there are a lot of great things about flying corporate versus the airlines, but there are two things that can really make things dangerous:

  • Fatigue
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Figure: Window of circadian low, from Duty/Rest Guidelines for Business Aviation, §1.0.

It is a common misconception that corporate aviation crews are less susceptible to the effect of fatigue than those flying for airlines. This is 180 degrees out from the truth. A scheduled airline more often than not has its crews bid for trip schedules that tend to be fairly regular. A crew flying the midnight run to Rome will have a chance to plan for that and become acclimated to that schedule. If you are flying a business jet to Rome, planning on arriving at 6 a.m. so you can hit the ground running, chances are your crews are operating during the "Window of Circadian Low." They are prime candidates for fatigue and are unlikely to be at their best for the approach and landing. More about this: Fatigue.

  • The perceived need for "smoothness."

Have you ever been in the cabin of an airliner and watched the landing from your cabin window and something seemed a bit wrong? If I am asked I will usually say it is too hard to judge a landing from the cabin but that is only partially true. I grade all landings on specific criteria. A good landing occurs off a stable approach that crosses the end of the runway at 50 feet and touches down between 1,000 and 1,500 feet from the approach end of the runway, and it does all this at the correct airspeed and after a smooth power reduction. In a Gulfstream, that power reduction should begin around 50 feet and end just as the wheels touch. The touchdown should be firm to make the landing computations work out.

As a passenger, you don't have access to all those criteria but you do have a better view on where the airplane is touching down because you are closer to the wheels and have a side view. From the cockpit our eyes are looking well forward.

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Drawing: Runway aim/touchdown zone markings (Approach end of Runway 4 at KLGA

Most runways have large white stripes painted on each end to create aim points and distance cues for pilots. The number of markings vary with runway size, but you will usually see a very wide mark 1,000 feet down the runway. The pilot should be aiming for this point and you should be touching down just beyond it. If you touchdown before these very wide marks, the pilot aimed short. If you see the double or single thin marks, the pilot has landed long. Either way is dangerous. Why would the pilot do that? If short, the pilot may be worried the runway isn't long enough. If that's the case, perhaps airport selection is an issue. If long, the pilot may have been taking unnecessary risks for the sake of that very smooth landing. And here is a secret: a landing's smoothness doesn't make it good.

As pilots, we should be pushing ourselves to get those landings between 1,000 and 1,500 feet, on speed, on centerline, and with a solid touchdown that will serve us well on a long, dry runway as well as a short, wet runway. If the passengers ask, we need to educate them about what makes a good landing. As passengers, if you hear the power come to idle and it takes another 30 seconds to touchdown, something isn't right. If your pilots are throwing safety out the window for the sake of impressing the boss on landing, they may have normalized deviance.

The "Mission Accomplishment" push towards Normalization of Deviance

So you are an aviation professional, highly trained, disciplined, and able to judge for yourself the balance between the need to accomplish the mission and the need to keep things safe. Me too. And yet I found myself in this ridiculous situation on my first international trip as a civilian:

  • Pre-departure 2.0
  • LIMJ - LIMF 0.5
  • Turn, wait for passengers 1.5
  • LIMF - CYJT 6.3
  • Turn 1.0
  • CYJT - KBOS 2.1
  • Turn 1.0
  • KBOS - KIAH 3.8
  • Post flight 0.5

That's a 20 hour day for two pilots and one flight attendant. This was in March of 2000 and the leg into CYJT was after going missed approach at CYQX. On the last leg into Houston I rested my eyes for a bit only to hear Atlanta Center yelling at some poor sap that wasn't paying attention on the radio. It wasn't me, but I wasn't sure if I had fallen asleep or not. I looked over to see the other pilot was sound asleep. We had a forward galley and the flight attendant was slumped over in her seat too, sound asleep.

Needless to say I was concerned and asked the chief pilot of this large flight department why we didn't preposition a crew in Boston. He explained that this was a regular trip that used to be to London and was easily done with one crew in our 14 hour limit. Then it started going to Munich, adding an hour. They waived the duty limits for the return leg, now pushing us to 15 hours. When they moved the destination to Rome, 15 became 17. Our missed approach at Gander took us to 20. So you see, he explained, nobody's fault!

The next time the same trip was scheduled I refused to take it. The chief pilot said it would be unfair to the other pilots if only I was exempted. Before too long, all of the other pilots were right behind me, refusing to fly the trip. So we started prepositioning crews to Boston.

I'm glad this happened to me during my first year out of uniform because it taught me that the system tends to push us into corners, and we in the business of providing air transportation fail to look around in that corner and don't realize the door is right behind us.

Why We All Fall (Even Me) Into the Normalization of Deviance Trap

Nobody sets out on day one to throw the rule book out; it is an incremental process. First you deviate slightly around a small, harmless rule. And then another. An another. Pretty soon you've waived the temperature limits on your o-rings.





The SOPs are too hard to follow (it’s the fault of the SOPs!)

We are extraordinarily good (and don’t need the SOPs!)

We can’t admit our failures in public (our jobs are on the line!)




The rules are written by

  1. Lawyers in Washington, D.C. and Brussels who are more worried about tax revenue than flight safety;
  2. Government bureaucrats that want a rule to cover every contingency so that when something bad happens, somebody else gets the blame;
  3. Aircraft manufacturers who know how to build airplanes but not how to fly airplanes; or
  4. All of the above.

It is pretty easy to conclude that there are so many rules and regulations out there that you can't know them all. You don't have to look very hard to find a rule or regulation that is obviously wrong, so you can be forgiven for doubting the value of any of them. BUT CONSIDER THIS: Even if all that were true, what's to say the one rule you didn't know about is the one that could have saved you, your passengers, or your aircraft?

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Photo: Pilots, (from movie "Big Trouble")

Of course none of this matters because you are extraordinarily good. You've never failed a checkride. You scored perfectly on every written exam. Whenever you go to an initial, the instructors are learning more from you than the other way around. BUT CONSIDER THIS: There are hundreds of case studies in the Abnormals section of this website and thousand more at www.ntsb.gov filled with pilots who felt the same way. How sure can you be that you aren't any different?

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Photo: Drill Sergeant, USMC photo

Most errors, we know, will never be caught. So if we catch our own errors, no harm, no foul. Right? Besides, admitting to our own mistakes only puts the spotlight back on us. And that can never be good. Right?

The Solution: The Normalization of Compliance

So right there we have the problem, and if we care to admit it, the solution. Turn the Normalization of Deviance into the Normalization of Compliance.

Make compliance easier (learn to appreciate your SOPs!)

Admit you are average (and need the SOPs!)

Don't be shy about your failures (you might save someone's life)

We all seem to be looking for the magic cure for the Normalization of Deviance. Perhaps an industry wide study to identify the problem. Oh wait, we've done that. How about a electrical device in the airplane to track conformity? You mean a Quality Assurance Recorder? Many airplanes already have those. In fact, the crew of N121JM had one. Okay, audits? What about better training?

All of that stuff helps. But the first thing we need to address are the aviators themselves. We, as leaders, can impact those problem aviators who never seem to get the word. Here's how.

Make Compliance Easier

Some rules are easier to follow than others, and some rules make more sense than others. Allowing people to pick and choose the rules they want to follow is a slippery slope. So you can ignore Rule A, so why not Rule B? The best way to avoid that problem is to find a way to adapt to the rules, formally waive the rules, or change the rules you disagree with. You might disagree with our solution to some of the example problems, these are just our solutions.

Make Compliance Easier: Adapt to the Rules

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Photo: Eddie on oxygen

Example: Oxygen rules — We are all told that 14 CFR 91.211 is the most violated FAR of them all. Since it is the most violated, it must be okay. I must admit I go back and forth on this. On the one hand, the rules are the rules. If you are flying a pressurized cabin above FL410, one pilot must wear an oxygen mask. If you are flying above FL350 and one pilot leaves the flight deck the other must wear an oxygen mask. If you are flying commercially, those flight levels decrease.

But, has there ever been an explosive decompression at altitude where wearing a mask was a factor? No, not that we know of. Is the oxygen equipment sterilized to ensure the pilot breathing pure oxygen won't be inhaling something that could produce long term health problems? No, the equipment is usually pretty much left alone after installation. Are the masks comfortable? No. Is anyone trying to get these rules changed and are they having an impact? Yes and no. The NBAA has been working on this for years; and the FAA has been ignoring it for years. So, job done then. Right?

Here is our approach to this problem:

  1. Improve the masks. We replaced our original equipment masks with much larger, more comfortable masks. The old masks were painful after five minutes. These ones are just a minor annoyance after an hour.
  2. Fly lower altitudes. We routinely plan all trips to go no higher than 41,000 feet. This means we don't have to wear the masks unless a pilot leaves a seat. (When a pilot leaves a seat, the other pilot does wear the mask.)
  3. Wear the mask at higher altitudes. If weather or performance requirements dictate higher altitudes, we take turns wearing the mask.

The controversy: this hurts our aircraft range performance and fuel economy. That is true. In a G450, flying at FL410 versus FL450 at typical weights can decrease fuel performance by as much as 0.02 nautical air miles per pound. That could be 250 pounds of fuel in an hour. About the same consumption as the APU.

My response: I can live with that.

Make Compliance Easier: Formally Waive the Rules

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Photo: Eddie's duty clock.

Example: duty limit rules — In our flight department of four pilots everyone has a job title and everyone, by our rules, can waive our fatigue rules. That gives us flexibility but also robs us of the protection of the rules. But over the years we have used that waiver authority less and less. We have also educated our passengers about the need to stick to set duty limits. We started out with a system that had no limits to one that does with waivers agreed to before the trip even commences. Now we have a system where the trip cannot be planned unless it meets our manual limits. And we've reduced those limits over the years so they now include reductions when flying during the Window of Circadian Low. (More about this, see: Fatigue.)

The controversy: giving each pilot waiver authority defeats the purpose of standard operating procedures and is just like not having them in the first place.

My response: It is a work in progress. My next step in the evolving process is to remove waiver authority for pilots on the trip, and my goal after that is to vest the waiver authority only in our dispatcher. We are a small flight department, managed in house. Just as we are learning to manage ourselves, we have to educate our users about our limitations. So far this year we've canceled ten trips because they just didn't fit into our duty rest limitations. We are getting there.

Make Compliance Easier: Change the Rules

Example: circling at night — Our company rulebook used to say we cannot circle at night with no exceptions. We wrote that thinking it was a best practice and certainly the safe way to go. But after having to divert once or twice we decided to rethink the issue. We agreed to put in an exception to the SOP, allowing night circling at VFR minimums for our home airport and three others.

The controversy: We found a rule we couldn't live with so we changed the rule.

My response: That's true. In this case the original rule was too restrictive and we changed it through our SMS program after long and considered discussion. We made the change as a group, gave it a test period, and adopted it formally.

Admit You Are Average

One of the hard lessons in life is that half of everyone in a graduating class, graduated in the bottom half of that class. It is true for pilots as well as doctors, everyone. Okay, you know that you are slightly above average, or even higher. I know that. But that can be a liability when it comes to complacency and any tendency towards the normalization of deviance.

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Photo: Where Eddie appears on any skills test.

You can draw a curve just like this one for just about any aviator metric you can think of: intelligence, cleverness, stick and rudder skills, instrument ability, etc. But no matter where you fall on any of these charts, you are at risk:

  • Goal Oriented Impulse — We all tend to be goal oriented and we want to accomplish the mission, no matter the road blocks put in front of us. But think back on those NASA engineers who kept lowering the minimum temperature for launch. Were they any different? You can be the best aviator in your flight department or the worst, you will have to face the pressure of letting your organizational goals override your common sense.
  • Experience-Driven — Even if you track relevant experience, low or high levels of experience can lure you into the normalization of deviance. Those who are very new to an aircraft or type of operation can be tempted to compensate by saying "it's no big deal" or "it's just another airplane." These people aren't taking the job seriously enough. On the opposite end of the spectrum, those with high levels of experience may achieve "guru status" and be looked upon as experts among their peers. These people are at risk of failing to realize the standard operating procedures have been put into place to protect them as well. Back to our NASA engineers: nobody had more experience in the space shuttle business.
  • Ego-Driven — It takes a minimum level of ego to get into the business of aviation. Not any mortal can defy gravity, after all. No matter where in the aviation food chain you are, just surviving for a few years where others have failed — we are talking all aviation professions here — that has to do a number on your ego. And your ego can lead you to believe the rules are meant for someone else, those that aren't as good as you.

So you have to admit to yourself that you are susceptible to the normalization of deviance. Knowing that, you should be able to recognize the signs in yourself and be that much closer to stopping it before it happens.

Leadership Notes

Your people are human, they make mistakes and they can fall prey to the normalization of deviance. You have a role to play here . . .

Don't Be Shy About Your Failures (and Successes)

Some mistakes are not so much willful deviations but circumstances conspiring against you. If you laugh off the mistake as "one of those things" or try to forget it as something you would rather not admit to your peers, you are missing an opportunity to fix things. The fix could spare you a repeat occurrence, or it could spare someone else from ever having to face the mistake in the first place.

An Example

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Figure: G450 Guidance Panel No Vertical Mode, from Eddie's aircraft.

A few years ago, I was flying over Ireland in my high-tech Gulfstream with the flight-level change mode of the autopilot doing a nice job of holding our Mach number and the engines giving us a steady 1,000-ft-per-minute rate of climb. As the autopilot captured our intermediate level-off altitude, FL350, Shannon Center re-cleared us to FL400. The first officer spun the altitude selector to the new flight level, I acknowledged the setting and got busy with verifying our oceanic clearance between our master document and the flight management system. Halfway through this task we got the dreaded, "Say altitude?" request from center. We were at 40,500 ft. and climbing an anemic 200 ft. per minute. We had flown imperfectly.

Shannon Center was very understanding and simply requested we chaps correct to our assigned flight level. I thought about this for a very long time. When we got back I convened a flight department meeting and we dissected the events as best we could. Even our youngest pilot had decades of international experience and I had over 20 years in Gulfstreams. This should not have happened!

We kept an eye on the automation to see if the problem would repeat itself. After three or four subsequent examples we figured out the autopilot's sequential thought process: (1) Altitude captured, vertical mode isn't needed so disengage it. (2) New altitude dialed in but no vertical mode, go to pitch hold mode.

So now, whenever the pilot monitoring moves the altitude select knob, the pilot flying verifies the selected altitude and vertical pitch mode. Because we made such a big deal of this, we've never fallen for the trap again. And I hope the word has spread among Gulfstream G450 and G550 crews.

More about this: G450 Vertical Mode Trap.

Another Example and a Reporting Mechanism

The thought of self reporting a deviation can be terrifying. "What are you? Nuts?" But if you can carefully shepherd the process through the first time it will get easier. The "troops" have to trust that leadership is not going to exact punishment on those who report. They must believe the process is intended to solve problems.

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Photo: Example deviation report.

You might also consider doing the report anonymously, but that is often impossible with a small group. If this report looks useful to you as is, you can download a PDF version here. If you would like to tailor the report, you can download a Word DOC version here.

Keep in mind that when I confessed to the rest of the flight department, I was doing so as the chief pilot, the top dog. This telegraphed the message to everyone that I was looking to them for help in solving the problem while acknowledging my performance fell short of perfection. That sets the tone for others to follow . . .

A Last Example and Another Reporting Mechanism

Sometimes the word "deviation" doesn't quite work and can be intimidating. We ask our PICs to submit a post flight log after every trip, even if nothing went wrong. (Sometimes every line says "no issues.") These forms have ended being invaluable when it comes time to track trends or just reconstruct the year. But they are also a good way to find out if someone needs a little training or something needs to be fixed.

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Photo: Example post flight log

I have been in flight departments where this kind of thing would be hushed up for fear of looking bad to the boss or drawing the ire of levels of management above the flight department. But we had instilled a culture where everyone realized these things happen and the best way to figure them out is to talk about them in the open. The two pilots freely talked about the problem. In this particular example both pilots had somewhat limited experience in the Gulfstream and didn't realize that the best way to descend in a given distance is to slow down and configure. We did some training and found the arrival does work, but you need to configure a little earlier.

If this report looks useful to you as is, you can download a PDF version here. If you would like to tailor the report, you can download a Word DOC version here.

Leadership Must Set the Example

You can do this as an individual or as a group. It is easier and more effective as a group; that takes buy-in from leadership. If you are the leader, read on. If you aren't the formal leader, remember an informal leader still leads.

Most aviation departments are unique in the world of bureaucracies in that the person in charge is usually a practitioner as well. The director of aviation or the flight department manager is often a pilot or a mechanic. As such they are prime candidates for the normalization of deviance and as such, will probably be the first to deny the problem even exists. If this is the case, very few subordinates will be willing to come forward and, in fact, will be more inclined to hide problems.

This is my third time at bat as the person leading a flight department. The largest group was 150, the smallest was 4, and the current group is 7. No matter the size, I always struggled to find out what was happening and struggled to get honest feedback from the troops. If you are sitting on top an organization of any size and think everything is going along as smoothly as possible, you are either very rare or very wrong.

So how do you set the example? Your actions speak louder than words.

Lead by example

You don't have to be "the" leader to lead. In one of my Challenger flight departments pilots did not do a navigation accuracy check prior to oceanic coast out and the chief pilot dismissed the practice as "eye wash." I always did one and when asked, demonstrated how such a precaution could save you prior to your first waypoint if there was a navigation system problem or waypoint insertion error. More and more of our pilots adopted the procedure and before long it became a flight department SOP.

Get outside audits

It is easy to fall into nonstandard behavior without an occasional look from someone outside the flight department. If the entire organization normalizes deviance at about the same rate, no one will notice because they are all involved. It may be beneficial to request an outside look at the inside of your flight department.

Honest SMS

There are many ways to adopt a Safety Management System, some easier than others. You can pay someone to come in and write your manuals and someone else to look at your manuals and call it done. You can even pay someone to give you a follow up inspection and say you are doing your best to live up to those manuals. This method involves minimal effort and robs you of the true benefit of a good SMS program: making you a better flight department.

FOQA

One of the problems with most pure general aviation business jet operations is a lack of oversight. Sure, you go to a name brand simulator training vendor every 6 or 12 months. But how objective can they be when you are paying them so much money? Okay, you participate in an SMS program. But some of those are better than others, and in the end you are paying them too. The best, most objective critique you can get comes from a Flight Operations Quality Assurance (FOQA) system. It is simply an electronic recorder that taps off the information you are getting from your flight data recorder, compares that to data from other users, and presents you with an idea of how well you are doing. It can't be bribed and it doesn't worry about hurting your feelings. I highly recommend it. Here is an example of a serving of humble pie.

We go to Atlanta Peachtree DeKalb airport every few months and for the longest time this view of Runway 21L bothered us. Especially me. The runway is 6,001' long but has a 1,200' displaced threshold. For some reason we just couldn't land that far beyond all that pavement. For years we justified this, saying we would visually pick up the PAPIs to keep things safe. But I think we all knew we were ducking under much more than that. Here is what the runway should look like if on a 3° vertical path for the touchdown zone. (I've drawn the red symbology to show what we would see through the HUD: the dashed line represents that 3° line and the middle symbol is the flight path vector. It shows where the aircraft is headed.) All is right with this drawing.

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Photo: A view of KPDK Runway 21L, on a good vertical path (HUD symbology added), from Eddie's aircraft.

Our first landing at KPDK after we had the FOQA system installed we — me — were flagged for ducking 2 dots below glide path about 400' AGL. (The black line is the aircraft, the purple line is the glide slope, the red line is 2 dots low.)

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Photo: FOQA report, KPDK, from Eddie's aircraft

This caused quite a stir with most our pilots and we were ready to make an exception to our stable approach rules, reasoning that it was insane to give up that much pavement. But then we started to compare KPDK with KPWK. If you touchdown where the glide slope hits the runway at KPDK, you have 3,801' remaining of the 6,001' runway. Runway 16 at KPWK is 5,000' long with the standard 1,000' touchdown zone marking, leaving you 4,000' remaining. So we are only talking about a difference of 199' here. We started flying the proper glide path at KPWK. FOQA has made us better pilots.

But isn't it expensive? Ours cost $13,000 fully installed and that was a Gulfstream installation. So no, it isn't expensive.

Training

One final thought, and that is about your recurrent training. Depending on aircraft type, chances are you have good vendors and not so good vendors. Some will say it doesn't matter, you are just looking to fill the squares and the quality of training isn't that different. That might be true for some aircraft types. My experience in the Gulfstream world — which in the last ten years has included the GIV, GV, G550 and G450 — is that you are far better off with the good vendor and you should avoid the not so good. But even if that isn't true I do have one more piece of advice.

If you like going to recurrent with members of your own flight department that's great because you can hone those crew coordination skills. But you might consider attending every other time with someone else. You might learn something valuable the vendor isn't teaching, or you might teach something too.

Foster an environment where everyone is willing to speak up

I believe that if you do all these things, you will telegraph your sincerity to normalize compliance. That will be the best thing you can do to prevent the normalization of deviance.

Shameless Plug

I said I am the Poster Child for the Normalization of Deviance and I think that is true. The difference between me and most deviants is that I post my lessons on line, write magazine articles and books about it, and speak publicly in an effort to help others to avoid these mistakes. I encourage you to learn from my mistakes and the mistakes I’ve noticed in others.

The website

Of course you are here already: www.code7700.com

The magazine articles

I've been published in several but my favorite is: http://aviationweek.com/business-aviation.

The books

There are four "Eddie" books out right now with one more to come. Each tells a story that touch on the subject of the normalization of deviance and my battle to overcome that. Find out about each: Book Notes.

Sources

Flight Safety Foundation, Duty/Rest Guidelines for Business Aviation, April 2014

NTSB Accident Docket, ERA14MA271

Vaughn, Dianne, The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA, The University of Chicago Press, Chicago and London, 1996.

Revision: 20171101
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