As I nearly crashed a plane worth £ 50 million and normalization of deviance

“Align it!” Came a scream from the back of my Tornado GR4 , but there was no need for it - I was already pulling the control stick towards me with all my strength!
Our 25-ton, full-fledged bomber had a risky dive angle of 40 degrees and shook furiously, while the wings, trying to obey the impossible commands, cut the air flow.

At that moment, when we fell out through the lower edge of the cloud, through my HUD (flight parameters indicator on the windshield), I saw even rows of fields on the ground: I felt uneasy.
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It was a bad thing.

A warning warning system about the dangerous proximity of the earth (GPW).
“WOOP, WOOP! “PULL UP, PULL UP!”

"7,6,5 - Tim, 400 feet left (approx. 120 m. - approx. Transl. )" - shouted the weapon system control officer (WSO).

We both knew that we were outside the capabilities of the ejection system.

How did I get into such a nuisance?

Let's stop.

Yes, sometimes you just need to stop.

And, in fact, it may not be so easy, especially if you have been doing something for a long time and it has become a routine for you.

For many of us, it can be bad habits, such as smoking, drinking alcohol, gambling - things that have become the life norm, but in no way do any good.

For others, it can be work habits - things that you have been doing for a long time and have become unchanged rules of work.

Although, sometimes it can be much worse.

Not so long ago, I learned about a plane crash, which shocked my colleagues so much that it gave rise to a discussion that sometimes so-called. “Accidents” must be
classified as something more intentional.

“An accident is an unpleasant incident that happens suddenly and unintentionally, usually leading to injury or damage.” - Oxford English Dictionary

It was an accident in 2014 in which the jet Gulfstream IV business crashed in Bedford, Massachusetts, after an experienced crew attempted to take off with the rudder locking mechanism (eng. Gust lock). The locking mechanism is a device that blocks the controls in order to prevent damage from wind exposure when the aircraft is parked. The take-off was interrupted at a late stage and the plane rolled out of the runway, fell apart and caught fire: all on board were killed.

The summary report of the incident included the conclusion that the crew did not attempt to check the controls before takeoff: they tried to take off with the locking mechanism involved and, realizing this, attempted to interrupt the takeoff, but it was too late.

The contributing factors included the crew’s usual neglect of checklist sheets. In fact, five checklists were not fulfilled: such ignoring was standard practice within the organization.

If the check in accordance with the check-lists were carried out, the locking mechanism would be disabled even before the engine was started. In addition, controls would be audited.

For professional aviators, however, it is obvious that the report implies that the cause of the catastrophe was what was called, in theory, “Normalization of deviance”.
For the first time, this term was used by sociologist Diana Vaughan in her book devoted to the Challenger shuttle crash - “The decision to launch the Challenger: high-risk technologies, culture and deviance in NASA” ).

“The social normalization of deviance means that people within an organization become so accustomed to deviant behavior that they do not consider it deviant, despite the fact that they grossly violate elementary safety rules” - Diane Vaughan

The longer this situation takes place in the organization, the more familiar it is for the staff. Third-party people consider this situation abnormal, but inside the organization it is a daily practice.

In some organizations, due to their large size, the described trend may be asymptomatic, even more rooting.

In 2003, Diana Vaughan was invited to join the commission to investigate the Columbia shuttle disaster and was able to explicitly demonstrate that NASA did not learn from the previous Challenger shuttle disaster using the same degree of risk tolerance and shifting to normalize risky operations.

“When we delved into the data, it became clear that the managers did not break any rules, but on the contrary obeyed all the requirements of NASA. After analysis, I realized that these rules were somehow “not so” - they differed from the usual order. People obeyed the need to keep pace with the schedule, and accordingly set the rules for how to make risky decisions. ”- Diana Vogan on NASA's internal mistakes.

NASA Employees Formulated Rules , submitting to our own assessments, which slowly degraded as the degree of urgency of launching the shuttles increases - we know how this happens.

As in the Gulfstream incident, the normalization of deviation often leads to a deterioration in the professional qualities of employees, which, in turn, leads to a slow and gradual degradation of the safety culture.

I felt this keenly during my tenure as a senior inspector of the largest air force in the Royal Air Force (RAF).

Due to the fact that many of my senior instructors left the squadron at the end of the service period, we were tempted to qualify less experienced colleagues for training in more difficult phases of flight — much earlier than this happened in the past.

And this brought us to a dead end.

If we did not qualify young instructors, we would have to place additional burden on the more experienced guys, increasing the risk of accidents due to their fatigue. But, if we were to hurry with the qualifications of young instructors, then such a risk would still have increased - because of their inexperience.

There was no win-win.

Fortunately, there were external organizations where we could turn for help, such as the Royal Air Force Central Flight School, as well as psychologists from the Center for Aviation Medicine: in our case, a compromise was found.

However, sometimes it is too late.

In 2011, two of my friends, being members of the Red Arrows aerobatic team, died in crashes. Because of my extensive experience in piloting the Hawk T1 (the plane on which the aerobatic team is flying), I was ordered to join the commission of inquiry as a narrow-profile specialist, helping to write the final report.

The incident I was investigating was a catastrophe in which, while attempting to land after a program in Bournemouth, my friend was killed. Despite the fact that the reasons for the crash were mostly medical, our report pointed to many areas in which the aerobatic team suffered from “normalizing deviance.”

As you see, “normalization of deviance” is found not only in large organizations, but also in small, cohesive units, such as aerobatic teams or parts of special operations forces.

This happens because it is very difficult for people from the outside to obtain relevant experience and knowledge in order to realize the “normality” of what is happening inside such a group.

I once talked to a member of the group whose task was to assess the flight standards of the Royal Air Force units, and he told me that while checking the actions of the Red Arrows pilot, he found himself upside down 100 feet ( about 30 meters ) above the runway Scampton airfield in battle formation with two planes a couple of feet away.

How should he assess the normality of what is happening?

He could not and he had to share his own experience with the advice of team members.

Once I knew a commander of a link who believed that his people were above opinions from the outside and that only he himself should evaluate and regulate their actions.

He was wrong.

To tell the truth, sometimes the assessment must go in part from the unit itself, but it is unacceptable to reject external regulation and supervision.

Think of the global financial crisis of 2008, when many banks burst just because they were not subject to external regulation, because they were able to convince the authorities that they themselves are capable of regulating their activities.

Look at it as if you are telling your friend that he is developing a bad habit.

Each of us would welcome such advice, even if we didn’t like it.
So that “normalization of deviance” is also found in individuals.

Take, for example, alcohol or drug addiction. As soon as you start using tobacco or alcohol, they quickly become the norm - in extreme cases, the person no longer remembers any other “normality”.

Sometimes this leads to the fact that the one who goes on this path, commits frankly stupid acts.

Like, for example, I, when I barely It was not crashed on its Tornado GR4 in Belgium in the mid-2000s.

Being a self-confident front-line pilot, I was sent to northern Europe to participate in international flight training. We had two airplanes and the contract between the crew members was such that we do not change them - if any of the machines fail, then its crew is on the ground all the time before the introduction of the aircraft.

It was a good deal.

Until our plane broke down.

We performed very well during the exercise. Acting like a pair of bombers, we hit all our targets and weren’t shot down by the Reds, who were portraying opponents. It got to the point that at the beginning of the second week a purposeful hunt began after us: the enemy wanted to boast that he shot down the planes of all the participating countries.

However, in the second week only one Tornado could get off the ground, and it was not my plane.

Our plane had a problem with the landing gear or landing gear - it did not close; chassis are not cleaned.

Aircraft found significant and irreparable wear of the mechanical lock of the retracted position. Theoretically, it had to snap into place at 0g, which meant that when cleaning the landing gear we needed to lower the plane face down.

I talked to my weapons control officer and we decided to give it a try.
We dressed in flight uniform and at that time, when all the planes were in the sky over Northern Germany, we took off to test the theory of our technician.

We raised the plane to 5,000 feet ( approx. 1,500 meters ), lowered our nose 40 degrees, reached 0g and gave the command to clean the landing gear. It takes about 10 seconds to fold the mechanism, the maximum allowable speed of the aircraft when it is folded is 235 knots ( about 120 m / s ), which, as we realized, turned out to be insufficient - having a nose slope of 30 degrees we were very close to speed .

We looked at the reference flight cards (English Flight Cards) and realized that we would have to develop a speed of 250 knots ( about 128 m / s ), which is a prohibited threshold (English Never Exceed limit).

In a normal situation, the development of such speed requires special approval, but then we felt the urgency and felt that we could be justified.

We measured several parameters and were pleased that, with due care, we could continue to take part in the exercises.

Having discussed our plan with the engineers and comrades from the second crew, we decided that everything was quite reasonable.

Until the next morning came.

The clouds occupied a height of 4,000 to 20,000 feet ( from approx. 1,200 to 6,000 meters .) - our space for maneuver was limited. If we succeed - we continue our combat mission, if not - we need to burn 5 tons of fuel before landing.

We took to the air while in the afterburner, then at a speed of 200 knots ( about 100 m / s ) I lifted my nose up to 40 degrees, removed the flaps and right in front of the cloud edge pushed the control stick away from myself.

Then I grabbed the chassis control lever and turned it to the “remove” position.
“Come on, come on!” I thought, while the nose of the 25-ton aircraft was slowly falling off the horizon.

I put the engine in low speed mode. At low speed, a large aircraft didn’t maneuver badly, and if the nose were lowered too low, it wouldn’t have time to even out before we hit the ground.

* Clunk, Clunk *

The chassis rose to the stowed position, and I turned the engines to full power and raised my nose to climb. There was plenty of time: we didn’t even drop below 2,000 feet ( about 610 meters ).

The plan worked.

For several combat missions we performed this procedure. Moreover, we managed to convince the dispatch service that what we are doing is normal.

However, people around suspected that something was wrong here: they began to ask questions, such as the American guy - the F-16 pilot, who also participated in the exercises:
“Guys, what the fuck are you having, for crazy maneuvers with a rollercoaster on takeoff?” He asked one evening after a few beers.

"The chassis is not removed while there is an overload," I replied.

“Oh, I get it - it just looks unusual for such a large aircraft, especially considering the amount of fuel on board,” he said.

I just smiled shyly.

The next few sorties were also calm, and “roller coaster maneuvers” became our normal practice when taking off from the airfield.

I was told that the program manager wanted to see me, and, as I was sure that our conversation would be devoted to our tricks on takeoff, I did everything possible to avoid him.

On the last day of our teachings, the weather was worse than in all the two weeks, but we really wanted to go home, not wanting to get stuck in Belgium for another weekend.

In the morning briefing, we were informed that the lower edge of the clouds was at a height of 1000 feet ( about 300 meters ) - lower than ever. This meant that when cleaning the chassis we had to be extremely careful.

We took to the air and remained at low altitude. At a speed of 200 knots ( about 100 m / s ), I pulled my nose up with all my strength, but I was able to reach only 30 degrees before we entered the cloud: it was something new.

I began to lower my nose, leaving the engine in the afterburner in order to achieve the necessary 0g.
"Chassis, come on!" I heard the voice of my WSO shortly after his phrase "1200 feet ( approx. 360 meters ), Tim."

The nose was lowered by 20 degrees.

“Come on!” I shouted.

It was going tight.

“Line up,” came a scream from the backseat.

When we got out of the cloud the nose of the car was lowered by 40 degrees and I realized that our business was sad.

Energy was not enough - the nose of the aircraft was rising too slowly to even before we hit the ground.

GPW system warning sounded.

“WOOP, WOOP - PULL UP, PULL UP!”

“7, 6, 5 - 400 feet left ( about 120 meters ), Tim!”, Shouted my WSO.

The plane was shaking despite the command of the controls: it simply did not have enough flight skills to get out of the dive.

Silence reigned in the cockpit. The situation was worsened by the fact that due to the high rate of decline we did not have the opportunity to eject.

I fully released the flaps and slats in order to increase the wing lift.

Its sudden increase led to the fact that the speed of movement of the nose of the aircraft to the horizon increased slightly.

The situation has improved.

In the end, I managed to level the plane at an altitude of 200-300 feet ( about 60-90 meters ) above the ground and I slowly raised the car back to the clouds.

The landing gear has not been removed. We waited a long and silent way home.

I was an experienced pilot, being just in the range when my overconfidence could lead me to death. The longer we performed the maneuver, the more confident we became.

We convinced ourselves that breaking the rules was beneficial to the teachings and that what we were doing was important.

But in this way, I almost crashed a military plane worth £ 50 million.

My actions to achieve 0g in order to clean the chassis after takeoff were against the rules, but they became familiar to us - I actually believed that I did everything right.

I was wrong.

We were lucky that day, but, as in the case of my “normalization of deviance”, as in the examples given, there were early warning signals:

• In the aerobatic team Red Arrows there were disasters in 2008 and 2010 with the loss of two aircraft. The squadron had its own unique method of piloting, as well as the level of training, which is extremely difficult for a person to assess from the outside.
• NASA lost the Challenger shuttle in 1986 due to negligence and continued to work with a vicious risk culture until the Columbia shuttle crash during its return to Earth in 2003.
• Everyone knows that jet pilots begin their journey with a full bag of luck, while starting to fill an empty bag with experience - most of the disasters happen at around 700 flying hours. When I almost crashed in Belgium, I had 650 hours.

"The trick is to fill the bag of experience before you empty the bag of luck."

Before you try to change the world, look where you started from.

Is it reasonable?

Did you deviate from what was normal for you?

I say “for you” because we are all different. We all have our own understanding, our own standards, but, in truth, we often deviate from them.

So not all at once.
Even before you collapse.

Maybe you should concentrate on fighting smoking before you bought a gym membership for £ 50 a month? Or stop eating chips and chocolate before you are completely dedicated to losing weight?

Do you know why, when you fly on a plane on vacation, they tell you to put on an oxygen mask first and then help the others?

Because if you do not help yourself, then you will not be able to help anyone.

Devote time to yourself - it's not easy, but worth it.

When preparing for takeoff, I always check whether the controls obey me, if anyone else is coming in for a landing (so that he does not land on my head) and whether the runway is free in front.

I also check whether the correct flaps are involved and whether the ejection system is on combat platoon.

I am convinced that I complied with the elementary rules of flight safety before undertaking it.

In that case, if, for example, a bird gets into my engine and tears off a compressor blade during takeoff, I will provide myself with the greatest chance to cope with the situation.

Ask yourself "what's stopping me from becoming what I want?"

And then you can concentrate on getting back to the basics of "yourself."

Link to the original publication (by Tim Davies)