"Accident - an unpleasant incident that happens suddenly and unintentionally, usually leads to injury or damage" - Oxford English Dictionary
“Social normalization of deviance means that people within an organization become so accustomed to deviant behavior that they do not consider it deviant, despite the fact that they grossly violate elementary safety rules” - Diana VoganThe longer this situation has place in the organization, the more familiar it is for the staff. Third-party people consider this situation abnormal, but inside the organization it is a daily practice.
“When we delved into the data, it became clear that the managers did not break any rules, but on the contrary obeyed all the requirements of NASA. After analysis, I realized that these rules were somehow “not so” - they differed from the usual order. People obeyed the need to keep up with the schedule, respectively, having tweaked the rules on how to make risky decisions. ”- Diana Vaughan on NASA’s internal mistakes. org/webt/_k/xr/29/_kxr29ydxahnpiaeecrnscak0iq.jpeg "/>, submitting to our own estimates, which slowly degraded as the shuttle launches become more urgent - we know how this happens.
As in the Gulfstream incident, the normalization of deviation often leads to a deterioration in the professional skills of employees, which in turn leads to a slow and gradual degradation of the safety culture.
I felt this keenly during my tenure as a senior inspector of the largest air force unit in the RAF.
Due to the fact that many of my senior instructors left the squadron at the end of the service period, we were tempted to qualify less experienced colleagues for training in more difficult phases of the flight - much earlier than this happened in the past.
And this brought us to a dead end.
If we did not qualify young instructors, we would have to place additional burden on the more experienced guys, increasing the risk of accidents due to their fatigue. But, if we were to hurry with the qualifications of young instructors, then such a risk would still have increased - because of their inexperience.
There was no win-win option.
Fortunately, there were external organizations where we could turn for help, such as the Royal Air Force Central Flight School, as well as psychologists from the Center for Aviation Medicine: in our case, a compromise was found.
However, sometimes it is too late.
In 2011, two of my friends, being members of the Red Arrows aerobatic team, died in crashes. Because of my extensive experience in piloting the Hawk T1 (the plane on which the aerobatic team is flying), I was ordered to join the commission of inquiry as a narrow-profile specialist, helping to write the final report.
The incident I was investigating was a catastrophe , in which, while trying to land after the program in Bournemouth, my death friend. Despite the fact that the reasons for the crash were mostly medical, our report pointed to many areas in which the aerobatic team suffered from “normalizing deviance.”
As you see, “normalization of deviance” is found not only in large organizations, but also in small, cohesive units, such as aerobatic teams or parts of special operations forces.
This happens because it is very difficult for people from the outside to obtain relevant experience and knowledge in order to realize the “normality” of what is happening inside such a group.
I once talked to a member of the group whose task was to assess the flight standards of the Royal Air Force units, and he told me that while checking the actions of the Red Arrows pilot, he found himself upside down 100 feet above the runway at Scampton airfield with two by airplanes a couple of feet away.
How should he assess the normality of what is happening?
He could not and he had to share his own experience with the advice of team members.
Once I knew a commander of a link who believed that his people were above opinions from the outside and that only he himself should evaluate and regulate their actions.
He was wrong.
To tell the truth, sometimes the assessment should go in part from the unit itself, but rejecting external regulation and supervision is unacceptable.
Think of the global financial crisis of 2008, when many banks broke only because they were not subject to external regulation, because they were able to convince the authorities that they themselves were able to regulate their activities.
Look at it as if you are telling your friend that he is developing a bad habit.
Each of us would welcome such advice, even if we didn’t like it.
So that “normalization of deviance” is also found in individuals.
Take, for example, alcohol or drug addiction. As soon as you start using tobacco or alcohol, they quickly become the norm - in extreme cases, the person no longer remembers any other “normality.”
Sometimes this leads to the fact that the one who goes on this path, commits openly stupid acts.
Like, for example, I, when I just it was not crashed on its Tornado GR4 in Belgium in the mid-2000s.
Being a self-confident front-line pilot, I was sent to northern Europe to participate in international flight training. We had two planes and the contract between the crew members was such that we do not change them - if any of the machines fail, then its crew is on the ground all the time before the aircraft is put into operation.
It was a good deal.
Until our plane broke down.
We performed very well during the exercise. Acting like a pair of bombers, we hit all our targets and weren’t shot down by the Reds, who were portraying opponents. It got to the point that at the beginning of the second week a purposeful hunt began after us: the enemy wanted to boast that he had shot down the planes of all the participating countries.
However, in the second week only one Tornado could get off the ground, and this was not my plane.
Our plane had a problem with the landing gear or landing gear - it did not close; chassis are not cleaned.
Aircraft found significant and irreparable wear of the mechanical lock of the retracted position. Theoretically, he had to snap into place at 0g, which meant that when cleaning up the chassis we needed was to lower the plane nose down.
I talked to my weapons control officer and we decided to try.
We dressed in flight gear and while all the planes were in over
Northern Germany, took to the air to test the theory of our technician.
We raised the plane to 5,000 feet, lowered our nose 40 degrees, reached 0g and gave the command to clean the landing gear. It takes about 10 seconds to fold the mechanism, the maximum permissible speed of the aircraft when it is folded is 235 knots, which, as we realized, turned out to be insufficient - having a nose inclination of 30 degrees we were very close to speeding.
We looked at the reference flight cards (Flight Reference Cards) and realized that we would have to reach speeds of 250 knots, which is a forbidden threshold (Never Exceed limit).
In a normal situation, the development of such speed requires special approval, but then we felt the urgency and decided that we could justify ourselves.
We measured several parameters and were pleased that, with due care, we could continue to take part in the exercises.
After discussing our plan with engineers and comrades from the second crew, we decided that everything was quite reasonable.
Until the next morning comes.
The clouds were 4,000 to 20,000 feet high — our room for maneuver was limited. If we succeed - we continue our combat mission, if not - we need to burn 5 tons of fuel before landing.
We took to the air after an afterburner, then at a height of 200 knots, I lifted my nose up to 40 degrees, removed the flaps and right in front of the cloud edge pushed the control lever away from me.
Then I grabbed the chassis control lever and moved it to the “remove” position.
“Come on, come on!” I thought, while the nose of the 25-ton aircraft was slowly falling off the horizon.
I put the engine in low speed mode. At low speed, a large aircraft didn’t maneuver badly, and if the nose were lowered too low, it wouldn’t have time to even out before we hit the ground.
* Clunk, Clunk *
The chassis rose to the stowed position, and I turned the engines to full power and raised my nose to climb. There was plenty of time: we didn't even drop below 2,000 feet.
The plan worked.
For several sorties, we performed this procedure. Moreover, we managed to convince the dispatch service that what we are doing is normal.
However, people around suspected that something was wrong here: they started asking questions, such as the American guy - the F-16 pilot, who also participated in the exercises:
“Guys, what the fuck are you having for crazy maneuvers with a rollercoaster on takeoff?” He asked one evening after a few beers.
"The chassis is not removed while there is an overload," I replied.
“Oh, I get it - it just looks unusual for such a large aircraft, especially considering the amount of fuel on board,” he said.
I just smiled shyly.
The next few sorties were also calm, and “roller coaster maneuvers” became our normal practice during takeoff from the airfield.
I was told that the program manager wanted to see me and, as I was sure that our conversation would be devoted to our tricks on takeoff, I did everything possible to avoid him.
On the last day of our teachings, the weather was worse than in all the two weeks, but we really wanted to go home, not wanting to be stuck in Belgium for another weekend.
In the morning briefing, we were informed that the lower edge of the clouds was at a height of 1000 feet — lower than ever. This meant that we had to be extremely careful when cleaning the chassis.
We took to the air and remained at low altitude. At a speed of 200 knots, I pulled my nose up with all my strength, but I was able to reach only 30 degrees before we entered the cloud: it was something new.
I began to lower my nose, leaving the engine in the afterburner in order to achieve the necessary 0g.
“Chassis, come on!” I heard the voice of my WSO shortly after his phrase “1200 feet, Tim.”
The nose was lowered by 20 degrees.
"Come on!" I shouted.
It was going tight.
“Line up,” came a cry from the backseat.
When we got out of the cloud the nose of the car was lowered by 40 degrees and I realized that our business was sad.
There was not enough energy - the nose of the aircraft was rising too slowly to even out before we hit the ground.
GPW system warning sounded.
"WOOP, WOOP - PULL UP, PULL UP!"
"7, 6, 5 - 400 feet left, Tim!", Shouted my WSO.
The plane was shaking despite the command of the controls: it simply did not have enough flying skills to get out of the dive.
Silence reigned in the cockpit. The situation was worsened by the fact that due to the high rate of decline we did not have the opportunity to eject.
I fully released the flaps and slats in order to increase the wing lift.
Its sudden increase led to the fact that the speed of movement of the nose of the aircraft to the horizon increased slightly.
The situation has improved.
In the end, I managed to level the plane at an altitude of 200-300 feet above the ground and I slowly raised the car back to the clouds.
The landing gear has not been removed. We were waiting for a long and silent way home.
I was an experienced pilot, being just in the range when my overconfidence could lead me to death. The longer we performed the maneuver, the more confident we became.
We convinced ourselves that breaking the rules was beneficial to the teachings and that what we were doing was important.
But in this way, I almost crashed a military plane worth £ 50 million.
My actions to achieve 0g in order to clean the chassis after takeoff were against the rules, but they became familiar to us - I actually believed that I did everything right.
I was wrong.
We were lucky that day, but, as in the case of my “normalization of deviance”, there were early warning signals in the examples:
- In the aerobatic team Red Arrows there were catastrophes in 2008 and 2010, with the loss of two planes. The squadron had its own unique method of piloting, as well as a level of training that is extremely difficult for an outsider to assess.
- NASA lost its Challenger shuttle in 1986 due to negligence and continued to work with a vicious risk culture until the Columbia shuttle crashed during its return to Earth in 2003.
- Everyone knows that jet pilots begin their journey with a full bag of luck, starting to fill an empty bag with experience - most of the disasters happen at around 700 flying hours. When I almost crashed in Belgium, I had 650 hours.
“The trick is to fill the bag of experience before you empty the bag with luck.”
Before you try to change the world, look at where you started from.
Is it reasonable?
Have you deviated from what was normal for you?
I say “for you” because we are all different. We all have our own understanding, our standards, but, in truth, we often deviate from them.
So not all at once.
Even before you collapse.
Maybe you should concentrate on fighting smoking before you bought a gym membership for £ 50 a month? Or stop eating chips and chocolate before you are completely dedicated to losing weight?
Do you know why when you go on a vacation, do you have to put an oxygen mask on yourself and then help the others?
Because if you don’t help yourself, you won’t be able to help anyone.
Devote time to yourself - it's not easy, but worth it.
When preparing for takeoff, I always check whether the controls obey me, if anyone else is coming in (so that it does not land on my head) and if the runway is free in front.
I also check whether the correct flaps are involved and whether the ejection system is on combat platoon.
I am convinced that I complied with the elementary rules of flight safety before undertaking it.
In that case, if, for example, a bird gets into my engine and tears off a compressor blade during takeoff, I will provide myself with the greatest chance to cope with the situation.
Ask yourself "what's stopping me from becoming what I want?"
And then you can concentrate on getting back to the basics of “yourself.”
Link to the original publication - by Tim Davies
From the translatorThe original article contains a number of technical terms related to the process of piloting airplanes mixed with military jargon. I, as a person little familiar with the specified topic, sometimes found it difficult to find the correct wording for translation (I tried no matter what =). If you found technical inaccuracy in my text, please write me a message!