As I nearly crashed a £ 50 million plane and normalized deviance

“Align it!” Came a scream from the back seat of my Tornado GR4 , but there was no need for it — I already, with all the force, pulled the control knob towards me!
Our 25-ton refueling bomber had a dive angle of 40 degrees and fluttered violently, while the wings, trying to obey impossible commands, cut the air stream.

At that moment, when we fell out through the lower edge of the cloud, through my ILS (flight indicator on the windshield) I saw even rows of fields on the ground: I felt uneasy.

The case was bad.

A warning about the Earth Danger Warning System (GPW) sounded.
“WOOP, WOOP! - PULL UP, PULL UP! ”

“ 7.6.5 - Tim, 400 feet left(approx. 120 m. - approx. transl. ) ”cried the weapons system control officer (WSO).

We both knew that we were beyond the scope of the bailout system.

How did I get in such trouble?

Let's stop.

Yes, sometimes you just need to stop.

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

For many of us, these can be bad habits, such as smoking, drinking alcohol, gambling - things that have become the norm, but in no way benefit.

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

Although, sometimes it can be much worse.

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

“An accident is an unpleasant incident that occurs suddenly and unintentionally, usually resulting in injury or damage” - Oxford English Dictionary

It was an accident in 2014, in which the jet-powered Gulfstream IV crashed in Bedford, Mass., After an experienced crew attempted to take off with the steering lock mechanism in use (gust lock). The locking mechanism is a device that blocks the controls in order to prevent damage from the effects of the wind when the aircraft is stationary. Take-off was interrupted at a late stage, and the plane, having rolled out of the runway, fell apart and caught fire: all those on board died.

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

Contributing factors included the crew’s habitual disregard for checklists. In fact, five checklists were not completed: such disregard was standard practice within the organization.

If the check in accordance with the checklists 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 disaster was what is called the “Normalization of Deviance” in theory.
The term was first used by the sociologist Diane Vaughan in his book on the crash of the Challenger shuttle - “The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA” (The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA) )

“The social normalization of deviance means that people within the organization are so accustomed to deviant behavior that they do not consider it deviant, despite the fact that they flagrantly violate basic safety rules” - Diana Vogan

The longer this situation takes place in the organization, the more familiar it is for staff. Outsiders will find this situation abnormal, but within the organization it is a daily practice.

In some organizations, because of their large size, the described trend may be asymptomatic, even more rooted.

In 2003, Diana Vaughan received an invitation to join the Columbia shuttle crash investigation commission and was able to explicitly demonstrate that NASA did not learn from the previous shuttle Challenger crash using the same degree of acceptable risk and shifting towards normalizing risky operations.

“When we delved into the data, it became clear that the managers did not violate any rules, but rather obeyed all the requirements of NASA. After analysis, I realized that these rules were somehow “not like that” - they differed from the usual order. People obeyed the need to fit into the schedule, accordingly adjusting the rules on how to make risky decisions ”- Diana Vaughan about NASA’s internal mistakes.

NASA employees formed the rules , subject to their own estimates, which slowly degraded as the urgency of the shuttle launch increased - we know how this happens.

As in the incident with Gulfstream, 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 acutely felt this while I was in the position of 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 the more difficult phases of the flight — much earlier than in the past.

And that led us to a dead end.

If we had not qualified young instructors, we would have had to put an additional burden on more experienced guys, increasing the risk of accidents due to their fatigue. But, if we hurried with the qualifications of young instructors, then such a risk would still increase - due to their inexperience.

There was no win-win option.

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, as members of the Red Arrows aerobatic team, died in a crash. Due to my wealth of experience in piloting the Hawk T1 (the plane the flight team flies on), I was ordered to join the commission of inquiry as a narrow field specialist, assisting in writing the final report.

The incident I investigated is a disaster in which, when I tried to land after completing a program in Bournemouth, my friend died. Despite the fact that the causes of the crash were mostly medical, our report pointed to many areas in which the aerobatic team suffered from "normalization of deviance."

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

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

I once spoke with 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 at a height of 100 feet ( about 30 m. ) Over the runway Scampton airfield in combat with two aircraft a couple of feet apart.

How should he assess the normality of what is happening?

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

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

He was wrong.

In truth, sometimes the assessment must partially come from the unit itself, but rejecting external regulation and supervision is unacceptable.

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

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

Each of us would welcome such advice, even if we did not like it.
So that the "normalization of deviance" is 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, a person no longer remembers another "normality".

Sometimes this leads to the fact that one who follows this path commits frankly stupid acts.

Like, for example, when I almost crashed on my Tornado GR4 in Belgium in the mid-2000s.

Being a confident front-line pilot, I was sent to northern Europe to participate in international flight exercises. We had two airplanes and the agreement between the crew members was such that we did not change them - if any of the aircraft crashes, then its crew is on the ground all the time until the aircraft is put into operation.

It was a good contract.

Until our plane broke down.

We showed ourselves very well during the exercises. Acting as a pair of bombers, we hit all our targets and were not shot down by “red” airplanes portraying opponents. It got to the point that at the beginning of the second week a purposeful hunt began for us: the enemy wanted to boast that he shot down the planes of all participating countries.

However, in the second week only one Tornado was able to 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; the chassis did not retract.

The aircraft technicians discovered significant and irreparable wear of the mechanical lock of the retracted position. Theoretically, it should have latched at 0g, which meant that when cleaning the landing gear we needed to lower the plane nose down.

I talked with my weapon system control officer and we decided to give it a try.
We changed into flight uniforms and at a time when all the planes were in the sky above Northern Germany, we took off to test the theory of our technician.

We raised the plane to 5,000 feet ( approx. 1,500 m.), lowered their nose by 40 degrees, reached 0g and gave a command to clean the chassis. It takes about 10 seconds to fold the mechanism, the maximum allowable speed of the aircraft when folding is 235 knots ( approx. 120 m / s ), which, as we realized, was insufficient - having a bow inclination of 30 degrees we were very close to speeding .

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

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

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

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

Until the morning of the next day.

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

We took off in the afterburner, then at a speed of 200 knots ( approx. 100 m / s ) I raised my nose up to 40 degrees, removed the flaps and pushed the control handle away from me right in front of the cloud edge.

Then I grabbed the chassis control lever and moved it to the “retract” position.
“Come on, come on!” I thought, while the nose of a 25-ton aircraft slowly fell over the horizon.

I put the engine in low speed mode. At low speed, a large plane maneuvered poorly and if its nose dropped too low, it would not have time to level out before we hit the ground.

* Clunk, Clunk *

The chassis got into the retracted position, and I put the engines in full power mode and raised my nose to climb. There was plenty of time: we did not even drop below 2000 feet ( approx. 610 m. ).

The plan worked.

For severalsorties we performed this procedure. Moreover, we were able to convince the dispatching service that what we are doing is normal.

However, people around suspected that something was wrong: they began to ask questions, such as, for example, an American guy - an F-16 pilot, who also participated in the exercises:
“Guys, damn you, for crazy maneuvers with American slides on take-off? ”he asked one evening after several glasses of beer.

“The chassis does not retract while there is overload,” I replied.

“Oh, I realized - 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 wants to see me and, since I was sure that our conversation would be about our take-off tricks, I did everything possible to avoid him.

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

At the morning briefing, we were informed that the lower edge of the clouds is at an altitude of 1000 feet ( approx. 300 m. ) - lower than ever. This meant that when cleaning the chassis, we should be extremely careful.

We took off and stayed at low altitude. At a speed of 200 knots ( approx. 100 m / s ) I pulled my nose up with all my strength, but I could only reach 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 reach the required 0g.
“Chassis, come on!” I heard the voice of my WSO shortly after his phrase “1200 feet ( approx. 360 m ), Tim.”

The nose was lowered by 20 degrees.

“Come on!” I cried.

Things went tight.

“Align” - came a scream from the back seat.

When we left the cloud, the nose of the car was lowered by 40 degrees and I realized that our affairs were sad.

Energy was not enough - the nose of the plane rose too slowly to level off before we hit the ground.

A warning from the GPW system sounded.

“WOOP, WOOP - PULL UP, PULL UP!”

“7, 6, 5 — 400 feet ( approx. 120 m ) left , Tim!” Cried my WSO.

The plane was shaking despite the command of the governing bodies: it simply did not have enough flight qualities in order to get out of the dive.

Silence fell in the cockpit. The situation was aggravated by the fact that, due to the high rate of decline, we were not able to eject.

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

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

The situation has improved.

In the end, I managed to level the plane at an altitude of 200-300 feet ( approx. 60-90 m .) Above the ground and I slowly lifted the car back into the clouds.

The landing gear has not been cleaned. A long and silent journey awaited us.

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

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

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

My actions to achieve 0g in order to remove the chassis after takeoff were a violation of the rules, but they became familiar to us - I actually thought that I was doing everything right.

I was wrong.

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

• In the Red Arrows aerobatic team, disasters occurred in 2008 and 2010 with the loss of two aircraft. The squadron had its own unique way of piloting, as well as a level of training that is extremely difficult to evaluate for a person from outside.
• NASA lost the Shuttle Challenger in 1986 due to negligence and continued to work with a vicious culture of risk 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 at the same time filling an empty bag with experience - most disasters happen at around 700 flight hours. When I nearly crashed in Belgium, I had 650 hours.

“The trick is to fill the bag of experience until you empty the bag with luck.”

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

Is this reasonable?

Have you deviated 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.
Line up before you collapse.

Maybe you should focus on smoking control before you buy 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 take a plane on vacation, you are told that you first need to put on an oxygen mask on yourself, and then help the others?

Because if you do not help yourself, then you cannot help anyone.

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

In preparation for take-off, I always check whether the controls are subordinate to me, whether anyone else is landing (so that he does not land on my head) and whether the runway ahead is free.

I also check to see if the correct flaps are engaged and whether the bailout system is on the platoon.

I am convinced that I obeyed the basic rules of flight safety before embarking on it.

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

Ask yourself “what prevents me from becoming what I want?”

And then you can concentrate on returning to the basics of “myself”.

Link to the original publication (author - Tim Davies)