This article popped up a couple of days ago...
Bedford and the Normalization of Deviance |
Analysing a G-IV accident I hadn't previously been aware of, but now am. There's a link in the article, but here's the NTSB report directly...
http://www.ntsb.gov/investigations/A...ts/AAR1503.pdf
It's a very interesting analysis, on a report where the causes of the accident are nonetheless distressingly obvious. It did get me thinking: in particular the value of this term "normalisation of deviance", which is related I think to James Reason's concept of the way in which human beings routinely using skill to circumvent failings in deficient systems: rather than to try and achieve corrections in a faulty system.
But how many times have any of us seen this? Aviation professionals (pilots being the obvious candidates, but I'd argue that it goes far wider than that) who routinely do their own thing because they have come to regard some aspect of published procedures as unnnecessary / overly onerous / pointless. Until, as in this case, it bit them.
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