Normalized Deviation By LT Lena Reid, USN
C
ould you describe the culture at your squadron right now? Does your command promote a high emphasis on safety and by-the-book maintenance? Is your command willing to bend a few rules to make the flight schedule or maintain op-tempo? Unfortunately, it usually isn’t until we have loss of life or aircraft that questions begin to get asked on how we got to this point. Normalized deviation, or unsafe norms, can go on for years without being noticed and is even sometimes encouraged as long as the mission is getting done. When this occurs, it is up to squadron safety departments to sound the alarm and challenge the cultures that permit normalized deviation. A norm is established within a group of people, through mutual agreements, how they communicate, interact, collaborate, etc. A norm is not universal however, since those within the Navy H-60 platforms will probably not be found in the Army H-60 community. Norms can vary with location (Norfolk Vs. San Diego), aircraft type/model/series, and with the biggest factor: leadership. If a deviation is allowed to continue, it leads Sailors to perceive these deviations as routine or acceptable. This “norm” will manifest due to various factors: repeated exposure, lack of consequences, or social and organizational influences such as seeing others bending rules whether they be peers or leadership. Most importantly however, deviations often will continue due to a lack of education on previous mishaps and/or hazard reports (HAZREPs). It's important to have an honest discussion within your wardroom to include maintenance personnel on current squadron norms such as the importance of by-the-book maintenance or why we use certain currencies for DVE or shipboard landings. Aircrew and Sailors have died because of bad norms. They have died due to the Navy’s lack of communication, a lack of understanding/teaching, and because young Sailors fear reprisal when they make a mistake and are afraid to own it. Something we do really well, debriefing tactical grade cards, does not translate to everyday flights or to maintenance. There is a lesson learned in every evolution we do, yet it is not debriefed in a way that everyone can learn. We cannot operate safely and efficiently if we can’t have an honest discussion about our shortfalls. In the last 5 years, the Sierra/Romeo Community has had 11 Class A mishaps and 7 Class B mishaps. This number does not include the 2 Class A mishaps that have already occurred in FY24. All of these mishaps included an underlying factor traced back to procedural non-compliance either from the aviators or from maintenance practices, which in total resulted in 4 loss of aircraft and 5 aircrew fatalities.
The question then becomes: why were Sailors and pilots not following procedures? Was it lack of training? Lack of understanding? Malicious intent? Bad norms? We can say for certain that Sailors are not purposely trying to hurt one another and rule out malicious intent. However, lack of training and understanding can be both rolled into bad community norms. The lack of instruction on case studies with previous mishaps, and the general lack of understanding of what could happen when not following procedures properly, both come about through a culture that permits normalized deviation. All 5 deaths were caused by maintenance malpractice, by Sailors skipping steps that were deemed not necessary even though there were warnings written that skipping those steps could cause loss of aircraft or even death. Those are five families that will never see their loved ones again because we as a community, maintainers and aviators, did not recognize this normalization of deviance. How do we fix this? If you are not sharing mishap and HAZREP reports with your wardroom and maintenance department, you are failing. What’s more, just droning through a powerpoint about ORM and normalization of deviance, is not how you train young aviators and Sailors on how to recognize risk and deviation. It's easy for commands to get a check in the box by giving lackluster training at safety stand downs. We need to stop doing this. When we have training days, we need to actually have meaningful discussions and review case studies in focus groups. One of the things we do not do well as a community, especially since the Navy has transitioned to RMI for SIRs and ASAPs, is quickly and effectively disseminate safety information to personnel. We need to do better at learning from previous events and passing down information to those who will eventually replace us. That is why it is critical for ASO’s to share and review mishap and HAZREPs with their wardroom and the maintenance department. There is a saying that there are no new mishaps, just new people recreating old mishaps, and to some degree this is true. Normalizing deviance will continue if we do not change the way we operate. Squadron safety representatives need to communicate and disseminate case studies not only to aviators but also to maintainers. When it comes to mistakes, we need to be honest with not only ourselves but with our leadership. Be able to have professional conversations and debrief community issues and lessons learned within your maintenance department and wardroom. If we don’t change the way we operate, we will continue to have this discussion and continue to see mishaps due to procedural non compliance and bad norms.
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