Claybird;
Re, "
This reminds me of how the Space Shuttle Columbia's accident investigation board described NASA's approach to safety."
Diane Vaughan, writing in "
The Challenger Launch Decision: Risky Technology, Culture and Deviance at NASA", described the lowering of standards due to past successes as the "
normalization of deviance." In the case of Challenger, successful launches occurred at lower temperatures with only moderate burn-through of the sealing O-rings. The engineers argued that launches had not occurred in such low temperatures but management over-ruled the engineers, citing history. Lack of resiliency was considered but until Feynman's now-famous demonstration with a small piece of O-ring, a pair of small vice-grip pliers and his glass of ice-water, the true effects of low temperatures had not been appreciated by the managers and leadership.
The important factor here, aside from normalization deviance is the "new" understanding of organizational behaviour that everyone thought they were doing exactly the right thing. It is a variation on the groupthink theme. Vaughan concluded that there had been no "amoral calculation", (intentional avoidance of standards, and/or negligence). The normalization of deviance concept made visible previously invisible organizational behaviour patterns.
The argument for SOP adherence is grounded in these notions. It can be successfully argued I think that individualism in cockpits, (where a pilot, or the captain makes up his own procedures)
can and does work
until it doesn't and there is a (perhaps preventable) accident.
In such circumstances the rest of the crew is on his/her own in terms of CRM and otherwise assisting. I argued this in the AF447 thread; - the PF launched individual actions (pitching up) on his own without announcing, (as required by SOPs), what he was doing, without calling for the ECAM actions (as required by SOPs), and, ignoring CRM SOPs by not responding to verbal interventions, (mild as they were) from the PNF.
Judgement is always required in flying airplanes and that is not inconsistent with SOPs. One must know when SOPs must be strictly adhered to for the safety of the flight, and when they
must be flexible
also to ensure the safety of the flight. Is the problem today not knowing that boundary? I don't know. I do know that despite a slavish requirements which sometimes do not appear to make sense, SOPs are an advancement in flight safety. I know this because as a young oiler I used to keep notes on every captain I flew with and that had ended by the time I had become a First Officer. The one case that comes to mind where a compromise in cockpit SOPs caused the loss of the aircraft and all on board is the Air Canada DC8 accident at Toronto in 1970. See p.91 - 98 of the
Report, (give it a moment to load).
There is
no argument today for a wholesale setting aside SOPs in favour of individually-created "safer" procedures, especially in air carrier operations.
Perhaps a question that would help here could be, "
What circumstances might be more safely handled by varying or even ignoring SOPs, and what operational circumstances demand strict adherence to SOPs?" We all know that both circumstances do exist, otherwise the thread would not be so interesting!