Serious pilots all embrace a commitment to the concept of safety and I hope no one –except perhaps our recent Seattle Q400 thief– wants to end up in a “smoking hole”. But despite this commitment and embracing best practices, we are constantly challenged by the subtle “drift” of normalizing. “Procedural drift” is the result of our built-in human process of adaptation, driven by our urge to achieve greater efficiency and utility. Adaptation has made us the most successful species on earth, happily inhabiting every corner of the globe from the arctic to the slums of Mumbai. But it does not serve us well in maintaining safety in aviation.
The forces and adjustments that lead to “drift” are incremental, subtle and subconscious. As pilots, we are all self-selected, aggressive optimizers and we value the efficiency and utility of getting the job done (mission mentality). But in almost every case, this natural drive is opposed to our better angels of managing the risks and assuring safety. This dynamic process of “drift” starts with any non-standard procedure or short cut often very small. Let’s say that by “pushing the edge” a little, we are blessed with success. This may be a result of skill or entirely due to luck, but either way, with each “success” becomes a neurological and social “win” in our brain. Each success makes us feel good and reinforces the new behavior (see: brain chemical dopamine). With this change we start to “drift”and never assess “luck or skill.” Each success subtly transforms our personal standards and we subconsciously accept a new procedure that may add a risk. The GIV disaster at Bedford a few years ago was a perfect example of professionals who had drifted over years into a very unsafe operation. This crew was literally an “accident waiting to happen” and never through a conscious decision. This very same process fooled a very smart bunch of engineers and managers at NASA and brought down two US space shuttles! This process is built into our human software.
The normalization of deviance is defined as: “The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the [person or] organization.” Seven years after Dr. Vaughan’s book was published, it struck again. The shuttle Columbia came apart due to damage in its heat shield as it was re-entering the earth’s atmosphere, and seven more astronauts died. NASA had fallen prey to the normalization of deviance for a second time. Shuttles returning with damaged heat shields had become the norm.
Especially in the vacuum of personal flying, with no additional training or any outside objective comparisons, a “personal standard” can develop into some very unique procedures quite contrary to safety. This is why the simple addition of hours does not create safer pilots; it may instead create a very weird and dangerous pilot. (And this is one reason professional pilots revisit the mother ship every six months) Without a supporting professional organization and regular critique, drift and normalizing are almost inevitable in piloting. That is why frequent training and an affiliation to a professional organization (yes- SAFE) with a strong Code of Ethics are essential.
Dr. Bill Rhodes, an Air Force Academy Instructor, has studied pilot personalities extensively and points out lots of warning signs. Almost every time the biggest talker in the room with the “fifty mission jacket” is exactly the person to avoid and ignore. Their personal belief in their own abilities and skills, with no objective standard or verification, has led them to become a dangerous and “creative” aviator (often with the biggest ego).
Especially if you are a new pilot or instructor and value professionalism and excellence in aviation, seek out a proven, professional mentor to guide your growth as you explore and develop your new skills. This is especially important if you are a new aviation educator, in the business of teaching even more pilots (see last week’s blog). We can only sustain a professional standard as a group if we are professionals bonded together; its the human condition. For more on this fascinating process of normalization and drift, see Sidney Dekker’s book “Drift Into Failure” (As a professor he even became a professional pilot to study this process in at work in aviation) It turns out the more errors we expose and talk about the safer we are — not by ignoring the problem. Join SAFE, we are here for you-fly safely (and often).
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