By MR. STEVE PANGER, HQ AMC Flight Safety
AMC has been working hard for a few years now on proactive safety. You’ve probably heard about common programs like LOSA, ASAP, and MFOQA. They identified underlying concepts that are important and deserve future study, such as intentional non-compliance, normalization of deviance, and groupthink. All are interrelated and I’ll define them later, but here are a couple of recent safety incidents to illustrate them:
An aircrew was conducting a two engine running onload/offload (ERO) and failed to identify and respond to an engine overheat warning. This was partially due to the aircrew constantly clearing warnings due to changing cargo door and ramp reconfigurations, which most likely desensitized the crew to other caution messages. This is an example of intentional non-compliance of standard operating procedures (SOPs).
During a recent mishap, due to the common practice within maintenance debrief of summarizing the pilot-reported discrepancy from the aircraft maintenance logbook to G081 (the maintenance data collection system), critical verbiage from the original discrepancy was omitted when transferring information into G081. This intentional non-compliance of standard procedures and a normalization of deviance resulted in an inaccurate representation of the discrepancy to the production staff and maintenance leadership. Then, due to complacency, the production staff failed to read the original pilot-reported discrepancy and did not properly status the aircraft or elevate the seriousness of the discrepancy. Groupthink perhaps?
As military members, we might be tempted to rationalize taking shortcuts with checklists because we operate in conditions of stress and feel pressure to perform quickly. Some even rationalize that we SHOULD shortcut our safety best practices when faced with conditions that we perceive are urgent. Individuals in certain conditions rationalize shortcuts to themselves, thinking, “There’s no time to waste. If I follow all the steps I’m supposed to, the mission will be delayed.”
The LOSA Collaborative (contractors who have been overseeing AMC’s LOSAs) defines intentional non-compliance as an error that meets one of four conditions:
Some LOSAs identified intentional non-compliance as a major subject area. These intentional non-compliance errors might move away from an SOP without incident, accident, or consequence but could develop into a normalizing of deviance.
When we get away with taking shortcuts, we are, in a way, rewarded for taking them. We remember the path to successful outcomes; if a path involved shortcuts, it may compel us to take shortcuts again because it’s a faster (and perhaps incorrectly considered more efficient) way to the successful outcome. Once we get enough previous successes that involved shortcuts under our belts, we let our guard down and consider standard procedures overkill. But the success might be based on luck—not skill.
When we rationalize shortcuts that are reinforced with positive (successful) outcomes, the shortcut becomes the new standard of behavior. When it happens on a large scale, no one within the organization notices because the behavior is the new “normal.”
Diane Vaughan, when writing about the Space Shuttle Challenger, defined normalization of deviance in part as “… people within the organization become so much accustomed to a deviation that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety.”
It can be easy to get drawn into deviations in the military. We operate so often with stress, consequence, time compression, and changing conditions that taking shortcuts to expedite successful outcomes can itself become “normal.”
Eventually, deviant behavior can become the norm, even grossly deviant behavior that seems outside the bounds of safety. This drift into failure can be slow, taking a significant amount of time for the new standard to become entrenched. Organizations often don’t see it happening. They are deep in denial that anything is wrong and defiantly defend their methods as best practices—even defending close calls, near misses, and casualty events due to their “dangerous profession.”
Irving I. Janus defined groupthink as “… a quick and easy way to refer to the mode of thinking that persons engage in when concurrence-seeking becomes so dominant in a cohesive group that it tends to override realistic appraisal of alternative courses of action.”
A recent LOSA SIB indicated several factors have contributed to normalizing deviance. The first is 15 years of combat operations, which has robbed our crews of adequate training time and resources. The second is a false sense of security, where a crewmember safely gets away with omitting checklists or briefings until that one time when a situation changes just enough to cause a mishap. The third factor is over-proceduralization—in other words, rules or procedures that are over-designed and do not match up with operational realities of simple tasks can cause crews not to feel obligated to complete a checklist step, or an entire checklist, contributing to normalizing deviance. After repeatedly accepting this lower standard, it becomes normal for crews to deviate from the published standards and accept that as the new norm.
According to Roger Baker (2005), intentional non-compliance errors are “born from a lack of flight crew discipline, or a lack of procedural clarity that makes it difficult for flight crews to comply with SOPs as written, or deeper systemic/latent factors such as operations pressure, scheduling-induced fatigue, and/or morale.” Baker contends that intentional non-compliance requires three factors: motivation (reward), high probability of success, and absence of peer pressure or reaction.
One could conclude that normalization of deviance is another form of groupthink reinforced by absence of peer pressure or reaction, as Baker stated.
Intentional non-compliance errors may or may not progress into an undesirable aircraft state (checklist not run properly, aircraft system not configured correctly, etc.) but could indicate a deterioration in flight discipline.
A couple of recommendations to consider:
› Do not use past success to redefine acceptable performance.
› Prevent groupthink; know and avoid its symptoms.
With few exceptions, aircrews and maintainers have been conducting safe and reliable missions and maintenance processes. Our intent is for this to persist. By continuing to conduct proactive safety programs, AMC Safety will help analyze root causes and educate AMC personnel about the pitfalls of intentional non-compliance, normalization of deviance, and groupthink behaviors.