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Old 4th Jan 2016, 15:45
  #23 (permalink)  
Ridger
 
Join Date: Jun 2013
Location: UK
Posts: 85
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'Deviance normalisation' are fine, sophisticated-sounding words, but wouldn't 'bad habits' do just as well?
I totally agree with you; bad habits describes it well but deviance normalisation (while just another label) is perhaps a little more informative a term,

Even better is just to describe the issue at hand rather than using such a label (the basis of Sidney Dekker's rationale in many ways) in the first place. Long checklists aren't ergonomic to use and probably contain many items which rarely (if ever) change state. Over a long time (years perhaps) the crew probably gradually omitted more and more of the 'static' items until they ended up with three actions: fire it up, taxi out and take-off.

Unless I missed it, one thing the report doesn't really mention is time - I would expect rushed or omitted checks to be partly driven by time pressure. If this was the case it may help explain the lateness of the t/o abort although many factors could have equally contributed to it.

Whatever the case, it's a very alarming occurrence which was completely avoidable and particularly harrowing, given that all souls survived the initial impact.

Last edited by Ridger; 5th Jan 2016 at 10:57.
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