Redefining Acceptable Risk When the Status Quo is a No Go

By MR. STEVE PANGER, HQ AMC FLIGHT SAFETY

DEFINITIONS

NORMALIZATION OF DEVIANCE

Diane Vaughan, in her report on the Space Shuttle Challenger Launch Decision, 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.â€

INTENTIONAL NON-COMPLIANCE

According to R. Baker (2005), “Intentional Noncompliance 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 [Standard Operating Procedures] as written, or deeper systemic/latent factors such as operations pressure, scheduling-induced fatigue, and/or morale. Intentional Non-Compliance requires three factors: motivation [reward], high probability of success, [and] absence of peer pressure or reaction. All three factors are required, or Intentional Non-Compliance does not occur.â€

GROUPTHINK

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.â€

Feb. 1, 2023, marked the 20th anniversary of the space shuttle Columbia tragedy. Much has been written on this incident, including comparisons with the space shuttle Challenger catastrophe, which occurred 17 years earlier on Jan. 28, 1986. Both disasters revealed that NASA accepted risks within the shuttle program discovered during previous flights, which had not performed as expected. These accepted risks added up, resulting in the mishaps. Also, in both instances, engineers most familiar with the relevant systems expressed concerns, but their concerns were overridden. Related in a safety sense are the fairly recent Boeing 737 MAX mishaps, which were also attributed to higher-level management concealing design flaws.

Safety is not only an engineer, maintainer, and crew member’s responsibility, it is also a leadership responsibility. Some leaders only address safety when an accident results in injury or damage. If those things are not occurring, safety may take a back seat to the mission.

One of the best examples in which Air Mobility Command (AMC) leadership has advocated for aviation safety in recent years is proactive safety. Line Operations Safety Audits (LOSAs), the Aviation Safety Action Program, and Military Flight Operations Quality Assurance are a few of the more common programs tackling these safety issues.

These programs have identified important underlying interrelated concepts (see definitions above):

  • Normalization of Deviance
  • Intentional Non-Compliance
  • Groupthink

The results of a number of LOSAs have identified intentional non-compliance as a major subject area. These intentional non-compliance errors might move away from a standard procedure without incident, mishap, or consequence but could develop into a normalization of deviance. When taking shortcuts, we accept risk, and often that risk is unnecessary. When we suffer no negative consequences, we are, in a sense, rewarded for taking this unnecessary risk. Remembering this path may compel us to take the shortcuts again because it is a faster (and perhaps even thought to be a more efficient) way to a successful outcome.

Our past successes can set us up for failure. Once we get an ample supply of previous successes under our belts while taking unnecessary risks, we may let our guard down to standard procedures that we now think were overkill. But the successful results might be based on luck, not skill.

As military members, in conditions of stress, we might rationalize that because we sense an urgency and a feeling of pressure to perform quickly, we can accept risk and deviate from our approved checklists. Some even go as far as to rationalize that we SHOULD shortcut our safety best practices when faced with conditions that we perceive as urgent. Individuals under certain conditions may sense that they have taken shortcuts successfully in the past and rationalize doing so by saying to themselves, “There is no time to waste. If I follow all the steps I am supposed to, the mission will be delayed.â€

Once we have rationalized our need to take unnecessary risks often enough, reinforced with positive (successful) outcomes, the shortcut becomes the new standard of behavior. It becomes the new “normal.†Even grossly deviant behavior—the kind of behavior that would seem to be outside the bounds of safety—can become the norm. This drift into failure can be slow, sometimes taking a significant amount of time for the new “standard†to become entrenched. Once these unnecessary risks happen on a large scale, many within the organization cannot see the risk in the behavior because it now seems like a normal way of operating.

Organizations or individuals that are drifting toward failure often cannot see it. They may be so deep in their denial that anything is wrong that they defiantly defend their methods as best practices. They can even defend their close calls, near misses, and casualty events by rationalizing that they are in a dangerous profession.

In the aviation environment, intentional non-compliance errors may or may not progress into an undesirable aircraft state (checklists not run properly, aircraft systems not configured correctly, etc.) but could indicate a deterioration in flight discipline.

An effective safety attitude relies on individual involvement. Setting the example, visiting work centers, talking safety with your peers, and being positive in how you go about your business are traits that the safety community should keep in mind when on duty … and off.

How would you describe yourself? Do you simply go through the motions, either lacking the courage to challenge the status quo or not caring? Have you run into Airmen who think safety gets in the way of the mission or safety is a roadblock to doing a job in an expeditious manner? We know a lot of personnel who are passionate about safety, but we also know some who are not. Some talk about a good safety game but may be all words and little action. Many others turn words into action; they are safety advocates.

Safety winners are advocates: courageous, selfless, passionate individuals who do the right thing to maintain or grow a positive safety environment. They genuinely care about people and the mission and seek lessons learned from events to prevent their reoccurrence. We set the example by doing the right thing for the safety of our people to successfully complete the mission. Are you setting the example?

Recommendations to consider as we trudge down the road of practicing safe principles in our day-to-day jobs:

  • Do not use past success to redefine acceptable performance.
    • Consider risk decision options after analyzing and objectively assessing scenario-driven probability and severity.
    • There is a difference between ASSUMING risk and CREATING risk. Those who have normalized accepting unnecessary risk have been creating risk for so long that it now feels normal. The more success they have had, the more normal it feels.
  • Prevent Groupthink; know and avoid its symptoms.
    • Ask someone on the team or crew to represent opposing views or ask everyone to voice their opinion before embarking on a mission or task.
    • Discuss areas of vulnerability in your area where it appears as though you may be drifting toward failure.
    • Discuss a close call or near-miss event where, in hindsight, it appears a contributing factor was a shortcut that members have been taking multiple times over a long period.

Bottom Line: With very few exceptions, aircrews and maintainers have conducted safe and reliable missions and maintenance processes. Our intent is, of course, for this safe process to persist. By continuing to conduct our proactive safety programs, AMC Safety will help to further analyze the root causes of Intentional Non-Compliance, Normalization of Deviance, and Groupthink behaviors and arm AMC personnel with the knowledge of the pitfalls of these behaviors.