Humans are really good at rationalizing. We do it all the time, every time when we cut corners, break rules or ignore evidence in pursuit of a successful outcome. We continue because it often has no consequences. The thing about rationalizing, though, is it can change our behavior. What once seemed wrong starts to feel normal, and outcomes that may be mostly due to good luck start to feel more like skill and deep understanding. In aviation, rationalizing can result in disaster.
For me, the best example of “Beware the false illusion of invulnerability” was Scott Crossfield who died flying a Cessna 210A into a thunderstorm resulting in his death. After all the years as a rocket pioneer and test pilot it appears he thought he could handle this storm which led to his making a very wrong choice.
“normalization of deviance.”
Great article Mike.
I first heard the term from a friend of mine, a local pilot and NASA engineer. We had a long interesting relevant discussion. Not that I was a risk taker but, looking back over a lifetime of flying for a living . . . well there were times.
Hoo boy, this principle, summed up in the subheading - “… if we think we got away with something, we’ll also think we can get away with it again” - is prevalent everywhere you care to look. I once worked at a family-owned tech business where ignoring the procedural norms was commonplace. It was even considered somewhat of a virtue, because it cut time off the production processes “as necessary” to meet shipping schedules. As the manufacturing and process engineer, I pushed back against this practice whenever I saw it, but the owner’s sons were the ones who managed production. They knew how much they could skew things toward the edges of the process envelopes and still have a reasonable expectation of success. yet on a regular basis, product would be returned by customers for noncompliance or even nonfunction due to defects. The owner would personally rub these customers’ shoulders over the phone and pledge that all units would be replaced ASAP. #1 & #2 Sons got a talking to and nothing else, and it was likely the replacements were rushed through mfg in the same manner as the originals which had been returned. I had to find another job because the situation was unacceptable.
Aviation has a lot of Stuff that pilots must keep at the forefront of their awareness. Finding an easy way to reduce the mental workload is sometimes welcomed, even when the pilot KNOWS it’s asking for trouble. It’s been said the FARs are written in blood, due to having found the limits of whtever envelope had been tested, and the results were then on display. Seriously - if a procedure has been identified that maximizes the probability of success, why not use it? The mfg business I worked for had a banner on the wall which read “If I don’t have time to do it right, when will I find time to do it over?” Apparently nobody read it. Unfortunately aviation seems to have a very restricted number of available do-overs.
It doesn’t just apply to aviation. If some people are “normalizing deviation” in the rest of their lives, why would they not in aviation? Deviation can be fatal in many areas of our lives - driving, being cavalier when it comes to disease prevention, handling firearms, etc. We need to think more carefully when involved in anything important.
My dad taught me to ride motorcycles, and we rode together often during my formative years. As an inexperienced rider, I often got butterflies before and during a ride–Dekker’s chronic uneasiness. It’s not a particularly comfortable feeling, and I asked my Dad once how long it took before it went away. “Son,” he said, “the day I stop feeling that way before riding is the day I stop riding.” It was a perfect answer that’s stuck with me my entire life; I still ride motorcycles today nearly 50 years later, and the butterflies are still with me.
Regarding the Gulfstream crash at Bedford, MA in 2014, it’s especially poignant that this tragedy resulted from a failure to use a checklist. The first B-17 prototype, known as the Model 299, crashed in October of 1935, killing two of the five occupants. The pilot lost control of the aircraft because he failed to remove the gust lock prior to takeoff. The event almost destroyed Boeing as an aviation company–it had bet all its resources on the B-17, and critics began to think the aircraft was too complex to be operated safely. But out of that tragedy was born an idea that has saved countless lives. A group of Boeing engineers and pilots devised a checklist for pilots to use as a memory aid. Boeing built another 12 aircraft, and its pilots, aided by checklists, flew nearly 2 million miles without incident. This ultimately convinced the U.S. government that despite its complexity, the B-17 could be safely operated by ordinary pilots. As we know, checklist use became mandatory for military aviators, and was soon adopted and mandated by professional commercial operators as well.
How sad then that a test crew elected not to use a checklist, thereby repeating nearly 80 years later the very same tragedy that prompted its creation.
I went to GIV initial in 2016, long enough after the Bedford crash so that FSI had all the information on that crash. It was a huge topic of discussion in the first two days of initial. The crew was FSI trained and according to the instructors, that crew was highly disciplined in the training environment but were a couple of “corner cutting cowboys” as my instructor put it. They were able to download enough information from the plane to see they hadn’t done the control check in the last—I think—60 ish flights. That means that between the time they started on the accident flight, till the time they tried to rotate, they never deflected the controls. Not once, no control check, no spoiler check, no hydraulic system check, nothing.
Back in the 1980’s I was sitting in the cockpit jump seat of a TWA 727 about to push back for takeoff from LaGuardia. This was the first trip of the month together for this crew. The Captain called for the pre-start checklist, and the flight engineer began reciting it, a list he had probably performed hundreds of times. The Captain turned to him and said, “Please read the checklist–if anybody’s memory is going to fail, I would rather that it be mine.” A statement that has stuck with me for all of my flying since, and most of my ground-pounder life as well. It’s the “why” of we have checklists, whether in the cockpit, the operating room, or on an ocean liner’s bridge.
I have been flying for 55 years or so, and it has been a constant struggle to make myself heed the wisdom of this article. I think a related problem is that of “task continuation bias”, the tendency of a pilot to continue with an original course of action that is no longer viable. The more skilled and experienced a pilot is, the more likely he is to fall victim to this well-recognized psychological problem. I had flown hundreds of airshows, for many years, when I succumbed to this malady, which nearly killed me and destroyed the most beautiful airplane that ever was. Google “Tumbling Bear” for more on the crash if you are interested.
Riding motorcycles is exactly what I thought about when reading that in the article. Not so much during, but before sometimes; a slight nervousness.
I’m reminded of Commander Charles Lamb (War in a Stringbag) trying to take comfort in the butterflies he had on some early missions (cited as his most unpleasant), in that they were “old friends” who he knew from the boxing ring, but that disappeared once the first bell rang.
While this has clear application to aviation, it can hurt you in other, more mundane activities. The clearest example is driving. Cars have become so comfortable, quiet, and electronic that it is no longer just about transportation. We need to be entertained as we drive offensively. We have forgotten that even modest superhuman speed is deadly and that IAMSAFE is a factor for how we drive and even whether we drive. Our attentiveness and overall skill have deteriorated just as this article has described: normalization of deviance, as if there are no consequences to bad behavior.
Be careful out there.
Just came back from the beach last night, 1h30 drive during the period sun was setting. Two incidents, luckily no contact but could have been. One an old boy, possibly drunk just wandered out of lane on the freeway in front of us, straddling the white line. Hard brake and short horn and he started like a rabbit back in lane. Other at a roundabout, young driver, driving fast and aggressively very nearly lost it and crashed into the typical mum with kids in the back.
Deviant behaviour in both cases. One old, probably been driving 50 years, other young, probably been driving two. In both cases I am sure they drive like that normally.
Cars pretty safe so probably if things went wrong, there would have been damage to cars and cuts and bruises to people. Not the same usually in aircraft.
A Well written article and good advice for more than just our flying lives. Being a safety engineer for more than 40 years, I can recall many cases where accidents were the result of several of the things you covered. One of the worst industrial accidents in this country was caused by a maintenance crew that prided itself in performing a cleaning task on a large chemical reactor faster by taking shortcuts from the prescribed procedure, thus “saving” the company valuable production time. Then one day, they got a little too quick and the reactor dumped several tons of a highly flammable solvent on the ground. The result was a huge explosion and fire that killed more than 20 employees, destroyed $1.2 Billion dollars of property and caused another billion dollars in lost production. The sad thing was that the local managers were aware of the crew’s activities and did not put a stop to it. Who’s the real guilty party?