Normalization of Deviance

  Jeneal McKinleyApr 24, 2017  

“Normalization of Deviance” is something that has come up in the past with a bunch of different accidents and is often associated with NASA.

The first time Bill read about it was after an accident back east in 2014. The definition is described as people in the organization have become so used to deviant behavior that they no longer consider it diviant anymore. Despite the fact that they have come up with rules under perfectly good conditions and now they’re deviating from them.

The people from outside the organization would look at that and say “that’s a dumb thing to do. Why are you doing it that way?” But the people on the inside of the organization have gotten so used to doing it in the non-standard way, that they no longer see it as deviant.

How does normalization of deviant develop? First of all a group with perfectly good intentions under no stress, sitting in a room, come up with a procedure, and they sit these high performance levels, generally they are safety minded procedures.

Under pressure, whether it’s time or budget or something else, you decide to take a lower level of performance standard to get the job done. So by taking this short cut and nothing happens, you continue to do that and nothing happens. That reinforces your belief that you can do it again.

One of the best examples is the Challenger explosion. We all know it was caused because of an O ring problem. The solid rocket booster, the two big rockets on the side of the shuttle, are built in three sections joined by O rings. Inside the booster is 5,000 degrees and 1,000 PSI.

When O rings were designed they were designated critical 1 pieces which meant if there was a problem you would instantly gound the fleet and solve the problem.

Fire was never supposed to get to the O rings, however the O rings were found damaged from the second shuttle flight. The fleet was never grounded. In fact, O rings were found damaged by fire in 14 of the first 24 shuttle flights. The Challanger was the 25th flight.

There was a memo from a NASA engineer stating that if the O rings failed they would lose the vehicle, the crew and the launch pad. He was off by 73 seconds.

Since there had been no failure to damaged O rings, NASA waived a critical 1 defect.

May 31, 2014, a Gulf Stream 4 crashed at the end of the runway at Bedford, Ma. Killing 2 crew and 4 passengers. The crash was due to the gust lock.

There are 4 pretake off checklists between engine start and the take off on a G4. They sckomplished none of them. In fact in 98% of their ‘ast 175 take offs they didn’t even do a control checklist. However that process got started, they got away with it until they didn’t.

On this flight the gust lock was not removed. On this plane it’s a big red handle on the pedestal that you can’t miss.

Actually, we learned this lesson 80 years ago. An Army pilot and a Boeing test pilot attempted to fly a B17 and couldn’t take off. The gust lock was on. After that it was decided to have a check list.

How do you avoid these types or shortcuts in flying, as well as in our life, like seat belts and texting? Astraunout Mike Moline presents to fire fighters and says it’s their responsibility to self and team to be a couragous self leader.

Use a checklist for every phase of flight.

Use it regardless if you are the only one in the plane or not.

Do a risk assessment of yourself as a pilot. Are you capable of what you are about to do?

Do an assessment of your aircraft for what you are intending to do.

What’s the environment or weather?

What external pressure are you dealing with? Do you have to get some place in a hurry?

Here’s a big one. Over the counter medications. Every one takes them. Have you flown after taking over the counter medications? Many over the counter meds are not approved like sedating medication. Benadryl is a good example. Zyrtec is another common one. Or how about Musinex, that’s another. Cold remedies, anything with a DM in it is sedating. The DM causes drowsiness and slows your response. Prohibitive medications have contributed to 12% of G. A. accidents and the number is going up, not down. 42% of pilots who died in accidents between 2004 and 2008 were found to be positive with drugs. That’s almost half of all the accidents. The most common drug was DM and it’s found in over 50 over the counter medicines. It’s extremely common and you may not even know you are taking it. Read the active ingredients.

Now that we are going to a non-AME kind of medical examination you need to make sure whoever gives you your medical exam understands that your a pilot. There may be things that they are not aware of that we can’t use as a pilot.

After using any medication with impairing side effects don’t fly until after 5 times the maximum dosage. So if the dosage says every 4 – 6 hours, 5 times that is 30 hours. So you need to wait at least 30 hours before you fly after taking the last dose.

But if you take it over and over again, for instance you have allergies and you use it a lot, it becomes a normalized deviance.

The FAA and AOPA website will tell you, or Google the medications and look for the side effects.

Eventually the normalization of deviance will catch up to you.