Normalization of Deviance - Flight Safety Foundation

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Human Factors

Normalization of Deviance

United Airlines equates casual noncompliance with stabilized approach criteria to NASA’s acceptance of risks before the final launch of space shuttle Challenger.

by Wayne Rosenkrans | June 8, 2015

Noncompliance with standard operating procedures (SOPs) — especially tolerance of unstabilized approaches — is a serious impediment to further reduction of accident risk, according to United Airlines safety leaders.

During his April presentation to the World Aviation Training Conference and Tradeshow (WATS 2015) in Orlando, Florida, U.S., Chris Sharber, a first officer and flight simulator instructor–Boeing 777 fleet, at the United Airlines Training Center in Denver, described the issue as invisible and insidious. United Airlines safety leaders echoed this theme in a keynote address and in presentations about analytical techniques and related insights from the company’s safety management system (SMS), including analysis of flight crews’ voluntary safety reports.

“We have somewhere between 11,000 and 12,000 pilots. Our new-hire department will bring another 1,000 pilots on board in the next 12 to 15 months,” Sharber said. “One of the challenges that you face with that many pilots, of course, is SOP compliance. How do you influence a group of 11,000 individuals to focus on SOP compliance, to maintain the tight standardization that’s required to maintain safe operations in a global airline?”

A key part of the solution has been to leverage the experience and influence of instructor-evaluators, flight instructors, simulator evaluators and line check airmen. In the most recent annual training review meeting of this entire group to identify safety, standardization and training issues, SOP compliance was raised as a significant concern. “The reason we’re sharing [this presentation] with you today is because the issues that we have are not unique to our airline,” Sharber told the attendees. The human factors involved also are not unique to aviation, he added, reviewing the original investigative commission’s findings and recent academic analyses of the Challenger accident on Jan. 28, 1986.

Location of O-ring pressure seals.<br>One of the academic analyses argues that although everyone involved was accustomed to mission-completion pressure as a factor in decisions regarding a Challenger launch, the fact that 24 previous launches had been successful with known leaks in seals (called O-rings) between rocket stages may have been the most important human factor, he said. Today, the term normalization of deviance — the gradual process by which the unacceptable becomes acceptable in the absence of adverse consequences — can be applied as legitimately to the human factors risks in airline operations as to the Challenger accident. “The shortcut slowly but surely over time becomes the norm,” in other words, he said.

Data Without Action

United Airlines pointed to the ironic possibility today of operating flights in an environment rich with objective quantitative/qualitative safety data and predictive analytics but not necessarily the will to take action. “Now we live in the data age, where we’re aware not only of what has happened but now we are aware of what might happen,” Sharber said. “In FOQA [flight operational quality assurance programs], the airplane gives us objective information. From ASAP [aviation safety action programs], we get the human story from the pilots themselves. We have the LOSA [line operations safety audit] study, [so] now we get information from objective outside observers. … So if SOPs and [other] procedures are based on all that valid information, why then would crews not comply?”

Several articles in AeroSafety World have covered recent research, including some led by Flight Safety Foundation, that offers credible answers, he said, citing the LOSA Collaborative’s data showing that acts of SOP unintentional noncompliance by airline flight crews occur slightly more often than twice per flight (ASW, 12/13–1/14). “Crews that are doing their absolute best to maintain the standard will have about two errors for every flight, so that’s our exposure — it happens every single day,” he said, because of lack of knowledge, unawareness of the SOP, improper training, insufficient study and the catchall term, just simple human error.

A particularly strong recent influence on such errors has been adapting to SOP changes associated with airline mergers. “Reversion to old procedure — falling back to old procedures — … has been a factor for my airline and for our industry here in North America, particularly the last several years,” he...