There was lurking on this forum about a month ago a link to a very interesting article on normalisation of deviance written by an RAF Tornado pilot. It was so interesting that I lifted it and included it in a safety newsletter for the pilots in the company that I work for.
The article referenced the Challenger and Columbia crashes as well as the G4 crash referred to in the OP but the primary interest was in his own tale of very, very nearly smashing a Tornado into the ground while trying to raise the undercarriage.
He was on a NATO deployment at the time engaged in an exercise in Belgium. All was fine until one day the undercarriage refused to lock up. The inspection showed a severely worn part that wouldn't let the undercarriage lock up. It couldn't be fixed. However, and this is where the deviation started, the pilot thought that if he slightly bunted the jet after takeoff thereby creating some negative g the undercarriage might lock up and the exercises could be continued. It worked.
However, during the week the weather worsened requiring more extreme handling to get the gear up (it took about 10 sec to cycle and there were speed limitations on the u/c). It all came to a head on the day they were to return to the UK when it went pear shaped as the cloud base was the lowest it had been. The aircraft wound up heading for the ground outside of the ejection parameters and was only saved by some extremely quick thinking. A very chastened crew then flew the aircraft back to the UK with the u/c down.
What he wanted to emphasise was that the deviation initially was not great but that it gradually grew as the week progressed and the weather worsened. The deviation had worked initially without problem so perhaps some further deviation will work without problem. And this is the rub, its more likely to be found the more experienced the crew.
They are the ones more likely to cut a corner because they have done it in the past without a problem and thus the deviation gets larger. That G4 crew were experienced and the NTSB report notes that on the recurrency training they did everything by the book but the flight data recorder noted that it was common practice for them not to do the pre-takoff checks at all. It had worked for all those times before why shouldn't it work this time?
I discussed the article with the CFI of the company I work for and he admitted to being guilty of it in the past and spoke about that occasion. He subsequently pulled himself up for his lapse and is well aware of the danger. We also had an example of a check-list not been done in circumstances where there was enormous pressure on the pilot to get going (weather, last light etc.). He neglected something that very nearly was fatal.
Want another example, the Costa Concordia. The company navigation plan called for (I think) a 5 mile distance from the island. That had been progressively lessened by the ships crew, all without problem until, of course, that night. Normalisation of deviance at its best.
I get the impression from reading some of the posts here that people think it can't/wouldn't happen to them. I beg to disagree; it can happen to the best of pilots when complacency becomes a factor.
Last edited by PLovett; 29th Mar 2016 at 04:11.