Close Calls

Normalisation of Deviance - Mirek Generowics

Safety, Normalisation of Deviance

Thursday 9 February, 2017

As part of National Safety Month 2016, we invited our members to submit stories relating to Human Factors.
Below is an article submitted by one of the competition's finalists:


Until recently I thought that ‘normalisation of deviance’ and ‘wilful blindness’ applied to other people. It ‘hadn’t happened yet’, and it was never going to happen to me. I thought that I was always careful and I was managing my risks consciously and deliberately. Now I know that normalisation of deviance is insidious. It can sneak up on all of us. We gradually become oblivious to a hazard when it develops slowly. The situation appears to be normal even though the danger should be obvious. We know we can get away with it, so we ignore the inconvenient truth, and we make those decision sub-consciously.

Flying a tailwheel STOL aircraft fitted with ‘tundra’ tyres enables you to operate on relatively rough terrain in paddocks. Over the past few years I’ve learned how to take off and land from extremely short and narrow strips in paddocks. Now I know the strips were much too narrow to be safe. I practised more than 700 take offs and landings. The challenge of landing in tight fields is rewarding and addictive. Year after year I slowly developed my skills and gained confidence, too much confidence. About one time in a hundred I’ve experienced some minor loss of control on take-off or landing. I’ve veered off the centreline, overshot or undershot the end of the airstrip and run my wheels into the crop. Every time I’ve gotten away with just minor damage to the wheat or barley, no damage to the aircraft. I gradually developed the confidence that nothing bad would happen.

This year we planted lupins and the growing season has been wonderful. The balance between rain and sunshine has been perfect and the lupins have grown really well. Lupins grow much thicker, taller and bushier than barley. But of course any crop takes many months to grow. Over the past five months I’ve run my aircraft wheels through the lupins at least three times. I could feel some drag on the aircraft but it was never enough to cause concern. By September the lupins were thicker, taller, bushy and heavy with seed. I was blind to the very obvious danger. On the day of the accident I chose to take off on a crosswind strip. Although an upwind strip was available it was 50 metres shorter and it didn’t have many good emergency landing options upwind in case of engine failure after take-off. The crosswind choice seemed to be safer. The crosswind was about eight to ten knots. As soon as the tail of the aircraft lifted on the take-off run the aircraft yawed into the wind, as expected. I applied full opposite rudder but straight away I could see that it would not be enough, I was heading straight into the lupins and aborting the take-off. Within two seconds the wheels were in the crop. The aircraft decelerated rapidly, somersaulting over its nose to land upside down.

Thankfully it is a sturdy aircraft with an effective roll cage around the pilot. The aircraft frame took substantial damage but left me unhurt to walk away and to think about what I had just learned. On the positive side, as well as having a roll cage I was wearing a four-point harness and a helmet. I had a mobile phone, air-band radio, GPS ‘spot’ tracker and a personal locator beacon. I had friends and neighbours who knew where I was and what I was doing, and who could come to help me.

I’ve also made a habit of using a cockpit camera on every flight. Video is a good tool for self-debriefing. It is always useful to be able to analyse each flight to see what could be improved. A video of the accident is on line at https://youtu.be/PSQ6vAfeG-8.

Sometimes we need to take a step back to look at the picture from a fresh perspective and to be more fully aware of the choices that we make. If we can become aware of our sub-conscious decisions we can then choose to make those decisions consciously, deliberately and being fully informed.

Aviation involves making many decisions that affect safety:

  • Choosing a runway that is too short given high temperature, high altitude or high weight,
  • Taking a chance with marginal weather conditions - such as a gusting crosswind,
  • Overestimating fuel endurance given headwinds stronger than forecast,
  • Choosing to risk VFR on top of clouds.

We should remind ourselves to make all of our decisions conscious and deliberate, and ask ourselves "What could possibly go wrong? What is my plan B?"

It is not just in aviation, many accidents happen closer to home in familiar surroundings. We become accustomed to situations that deteriorate slowly over time. We make subconscious decisions that compromise our safety. We might push our luck on the roads with speed limits or by rolling through stop signs. We might drink that second stubby of beer before the trip home. Perhaps we might be tempted to answer the mobile phone while driving, or to take a quick glance at an SMS. We might not worry about tying the ladder securely or making sure that it is level.

Taking a risk becomes our normal behaviour, because nothing bad has happened to us yet.