By Randy Mains W

hat can the helicopter world learn from NASA’s mistakes? I’m

specifically talking about the Challenger space shuttle disaster, and the cancer of normalization of deviance that was the root cause of that tragedy.

On Nov. 3, 2014, NASA Chief of Safety and Mission Assurance Terry Wilcutt and Deputy Chief of Safety and Mission Assurance Hal Bell put together a presentation entitled “The Cost of Silence: Normalization of Deviance and Groupthink.”

The term “normalization of deviance” was coined by Columbia University Sociology Professor Diane Vaughan in her detailed analysis of the Challenger disaster. She defines normalization of deviance as: “The social phenomenon that people within the organization become so much accustomed to a deviant behavior that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety. To people outside of the organization, the activities seem deviant; however, people within the organization do not recognize the deviance because it is seen as a normal occurrence. In hindsight, people within the organization realize that their seemingly normal behavior was deviant.”

Vaughn developed her theory of the normalization of deviance in her book “The Challenger Launch Decision.” She details how, during the developmental phase of the space shuttle program, the normalization of deviance resulted in a dangerous design flaw in the spacecraft.

10 Nov/Dec 2020

The group assessing the joints on the solid rocket boosters conducted analysis to find the limits and capabilities of joint performance. Each time, evidence initially interpreted as a deviation from expected performance was reinterpreted to be within the bounds of acceptable risk. The acceptance of this risk led to the Challenger exploding on the morning of Jan. 28, 1986.

Humans have a tendency to rationalize shortcuts under pressure, especially when nothing bad happens. The lack of

bad outcomes can reinforce

to check the elevator’s freedom of movement at 60 knots. With the gust lock in place, they were unable to set takeoff thrust and realized this, but still continued the takeoff and never reached the target thrust setting.


“rightness” of trusting past success instead of objectively assessing risk. Think about the five people who lost their lives strapped into the FlyNYON helicopter with known unsafe and unapproved safety harnesses.

Pilots who have accumulated years

of experience and a strong sense of confidence are at risk of normalizing deviance unless they have sufficient oversight and a strong peer group. The crash of Gulfstream G-IV N121JM on May 31, 2014, is a case in point.

The pilots started the engines without using

the engine start checklist and

neglected one of the steps, which would have them disengage the flight control gust lock. They then skipped the engine- after-start checklist, which called for the flight controls to be checked. Had they done this, they would have realized the flight controls were locked. They also skipped both the taxi and lineup checklists, as well as the requirement

The aviation community could not understand how two pilots had been so inept. The answers were in the aircraft’s quality assurance recorder. This type of behavior was the norm for them. The recorder revealed that they had skipped the flight control check on 98% of their previous 175 takeoffs.

These two pilots didn’t fly in a vacuum, as they occasionally flew with contract pilots who witnessed their habitual procedural non-compliance. By tolerating their deviance, the contract crews became enablers serving to reinforce the behavior as normal.

An article in, “Avoiding and Curing the Normalization of Deviance for Pilots,” stated: “At each stage of a new pilot’s growth comes a time where he or she is tempted to think, ‘At last I know what I need to know.’ Some pilots may even arrive at the ‘At last I know everything there is to know’ stage. With each new level of license and training, the concept of ‘You Don’t Know What You Don’t Know’ should become reinforced. The new pilot, if not careful, may end up in the ‘deviant pilot’ class without having ever accomplished any level of expertise.

“A new pilot who does not continue his or her education is at risk of stagnating

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