Normalisation of Deviance

In the 2012 Costa Concordia cruise ship accident, although the accident was largely attributed to the negligence of the Captain and crew, their actions were also an example of the normalisation of deviance in the cruise line business, as the behaviours that led to the accident deviated significantly form the Standard Operating Procedures (SOPs) but had become “the way it was done”.

Whilst the Normalisation of Deviance largely centered on the organisational and corporate culture for these two accidents, it is used more frequently today, not only focussing on organisations but it also applies to the behaviour of both individuals and groups.

In 2014, the accident of Gulfstream IV N121JM - due to a runway overrun during a rejected take-off - is a good example of not complying with SOPs and the Normalisation of Deviance leading to an accident. Both of the pilots deviated from using checklists and SOPs, a behaviour which had become established and normalised. The pilots failed to remove the gust lock and didn’t complete a check of the flying controls during their pre-takeoff checks. This then led to them attempting to get airborne with the gust lock fitted, resulting in the loss of the aircraft and all on board. This accident is both an example of poor individual behaviours, but also an example of ‘group thinking’ and resultant poor group behaviour.

Normalisation of Deviance affects us all and you will have been confronted with it in everyday situations. Have you ever sped up whilst driving, maybe whilst following a group of speeding cars ahead to get through traffic? Potentially (consciously) breaking the speed limit or even ‘jumping’ a red light? Behaviour that you most likely did not display when you passed your driving test, but you’re now doing it because other people are doing it without getting caught or having an accident? Have you ever set rules and boundaries for your children, to then renege on your own limits by allowing them to transgress ‘the rules’ to avoid confrontation or due to fatigue? Although you know it’s illegal, whilst driving have you ever looked at your phone when you hear a notification come through?  

What causes us to behave in this way? Why do we deviate from normal behaviours and rules and accept this behaviour as the ‘new normal’? Simply put, it’s because we are human. We cannot help the build up of small ‘rule breaks’ over time and before we know it, we always drive everywhere over the speed limit. Unless we recognise that we are doing it, and then make a conscious effort to question why we may have deviated from what we know and recognise as the ‘correct’ behaviour, we are likely not to know that we have normalised our deviated behaviour and will continue to act in that way.

Factors and influences that cause us to deviate from what is accepted as normal behaviour in the context that we are operating in, can range from a lack of experience or knowledge, to willful or deliberate violation. Being new to aviation or inexperienced on a new aircraft type is why we have systems in place to help, such as checklists, flight manuals and SOPs.

Remember that these systems and processes are for everyone, regardless of experience. The very experienced pilot crew of Gulfstream IV N121JM who had in excess of 24,000 hours between them, failed to comply with the aircraft checklists prior to take-off and also did not adhere to correct SOPs; the consequences were fatal.

Other factors that may cause us to deviate from normal procedures or checklists can be peer pressure or the ingrained culture of those around us – “we’ve always done it like that around here” – if you are the new person in the club or organisation, you may have a fear of speaking up against this sort of culture where deviance has been normalized.

In worse case scenarios, willful or deliberate violation may become the norm. It may not be intentionally malicious, such as finding a shortcut or a quicker way to get something done, or thinking that rules or procedures are inefficient, but this is exactly why we have checklists and SOPs in place to prevent things getting missed or mistakes from happening. Even the most talented and experienced test pilots use checklists and stick to SOPs as they recognise that mistakes can be made (after all, no-one is perfect) and in fact many have suffered as a result of cutting corners. But if we can get away with it without consequences, we are more likely to deviate from normal behaviour again – jumping that red light?

If complacency sets in or no action is taken against the negative behaviours that have crept in, this may give rise to breeding further activity of this kind, thereby leading to a downward spiral of more cut corners, consequently succumbing into Normalisation of Deviance.

Checklists and SOPs – Why do we have them?

The human mind cannot remember everything and the human memory is certainly vulnerable to error. Einstein famously quoted “Never memorise something that you can look up.” He was renowned for having a notoriously poor memory; he was unable to remember dates and could not even remember his own phone number! Whilst some items of checklists should be committed to memory, you should not be expected to remember everything in a checklist, that is why the manufacturer or aircraft operating authority has them in the first place. Similarly, SOPs have been created and developed as a way of capturing years of operating experience as ‘best practice’ so should be followed unless there is a good reason not to.

How to confront Normalisation of Deviance

As with the majority of challenges that we face in aviation, to do something about this, firstly we will need to recognise that our behaviours have changed. This is a fantastic first step but we now need to work out what caused this change and why. For example, when we are operating under conditions of stress, maybe with changing conditions and added time pressure, we can feel a sense of urgency and this can cause us to want to take a shortcut from what we would normally do in a more benign situation.

In this example, you probably already know that something isn’t quite right, but this is the time to take a step back and reassess the situation. For example, imagine you are taking passengers flying and they have arrived at the departure airfield later than scheduled. The weather at the destination airfield is now worse and deteriorating faster than was forecast, and of the passengers are now pressuring you to get airborne as quickly as possible, should you modify your behaviours and procedures to accommodate them, thereby potentially introducing a shortcut or the possibility of missing something (weight/aircraft performance calculations)? Or, should you take a step back, reassess the situation and maybe delay the departure, or even reschedule it for another day? What about next time? How do you avoid putting yourself in this situation again?

Conditions resulting in stress or urgency may not need to be apparent to cause a shortcut to be taken. If you are used to single pilot operations, it is quite likely that you may subconsciously or inadvertently create your own shortcuts. For example, if you are taking your friends or family flying you are likely to be distracted more than usual with questions or concerns for their welfare, possibly resulting in missing vital checks.

We should also avoid temptation to rationalise bad behaviors. This is particularly at risk when in a group environment with the potential for peer pressure to take over. The challenge here is to be brave: if in doubt, speak out; which is not always as easy as it sounds.

Summary

It is so easy for Normalisation of Deviance to creep in and if it is left unchecked, it will spread into other aspects of our lives. It can affect you as an individual, and if it extends into group behaviours is likely to have an impact at an organisational level. This will negatively influence the culture of the organsiation and all of the individuals operating within it, unless it is challenged by strong individuals or if the organisation has instilled a robust culture through resilient processes and SOPs. Don’t accept cutting corners or developing bad practices or behaviours. Stop. Think and use your checklists and SOPs to combat that deviation form the norm.

Further reading:

CAA Safety Sense Leaflets: Pilots: It's Your Decision and Good Airmanship Guide

https://www.amazon.co.uk/Challenger-Launch-Decision-Technology-Deviance/dp/0226851761

https://www.britannica.com/event/Challenger-disaster

https://skybrary.aero/articles/checklists-purpose-and-use

https://skybrary.aero/articles/standard-operating-procedures-sops

https://skybrary.aero/articles/adherence-sops-oghfa-bn