Jacky’s Classroom Talk (3): “Normalization of deviance”

Wednesday, March 25, 2020

What do the Challenger desaster and skydiving have in common?

How far do we deviate from our safety routines without even being aware of it?

Today is Saturday, 14 December 2019, and I am sitting in a long-distance coach travelling from Bielefeld to Hamburg. Along with me about ten other passengers. It feels quite a lot like in a drop plane. The coach is still parked, I’ve made myself comfortable: coffee, laptop, iPhone, AirPods.

Jacky has made herself comfortable in the coach. Photo: Jacky

The journey starts. Every seat has seat belts, and the bus driver is buckled up. There are big red warning signs in front, but none of the passengers fasten their seatbelts. I grab mine, drop it again, lean back. Then a thought crosses my mind: “In your own car, you would also buckle up. So why not here? Why isn’t anybody else wearing their seat belt?”

I also remember the constantly recurring discussion about seat belts in the drop plane. Although it’s written in the German skydiving training manual (Ausbildungshandbuch) and is part of our basic safety training in groundschool. For good reasons! So I grab my seatbelt again and fasten it. After all, there is no reason to deviate from a proven safety routine just because I don’t drive this bus myself. This brings an article (see link #1 at the bottom of this article) to my mind, which I once read on this topic, and I would like to copy some parts and add my own thoughts to it.

Normalization of deviance at the NASA

On 28 January 1986, the Challenger space shuttle crashed shortly after take off, killing the seven astronauts on board. The investigating sociologist Professor Diane Vaughan defined the term “normalization of deviation” in her book “The Challenger Launch Decision” (see link #2 at the bottom of this article). This phenomenon was identified as the fundamental cause of the tragedy. Diane Vaughan defined it as follows:

“The gradual process through which unacceptable practice or standards become acceptable. As the deviant behaviour is repeated without catastrophic results it becomes the social norm.”

In the case of the Challenger explosion

there was a known fault with the putty in the O-rings of the solid rocket boosters (srb). During launch gases from the srb would pass through bubbles in the putty and burn the O-ring. NASA continued to fly missions with no bad outcome, so gradually accepted the notion that it was safe to operate without addressing the issue – ‘normalization of deviance’. During the Challenger launch the gases burned through the O-rings and ignited the main fuel tank.

Normalization of deviance in our daily life

For some reason, we deviate from our security routine, even though we know it is dangerous: we type textmessages or make phone calls while driving, we walk around town with headphones on or in our ears, or we ride a bicycle with no lights on. Nothing bad happens, so we do it again. The third, fourth or fifth time, the deviation has become common practice, the new modus operandi.

We do not even notice that our own safety standards have changed. However, the danger has not been reduced even a little.

Normalization of deviance in skydiving

Also when skydiving, the deviation can easily be normalized. We all learn common, proven and safe practices when we start this magnificent sport. It is no coincidence that already in ground school 80% of the time feels like practicing emergency procedures.
But only a short time later, we put our safety at risk by deviating from the well-proven routines. Quickly, shortcuts are taken, trained routines are ignored or changed. The reasons are as numerous as the excuses. But far too often, the truth is:

What ultimately leads to tragedy is simply complacency, simple arrogance or an incapacity to cope with the pressure exerted by others.

Green light

There are good reasons to take a look down before the exit. We’ve all been taught that.
On a sunny day, you jump at your home drop zone where everything is very familiar to you. You’re the first group to exit, the green light goes on and you exit the plane without looking down. The spot is perfect and the jump uneventful. By a few more jumps, you don’t even think of looking out the door; the pilot’s spots are consistently excellent. What if one day there is another aircraft directly underneath, or the spot puts your group in danger? If you were jumping at an unknown dropzone, near the sea or a huge forest, you’d damn well look out the door, wouldn’t you!?

Danger can strike at any time in our sport and usually when we least expect it. Deviating from established methods makes that danger more likely to do harm.

Are you guilty?

There are many examples… Do you recognize yourself in one or even multiple of them?
Example 1: You have neglected your jump preparation

Little carelessness during the gearcheck and jump preparation quickly becomes a (bad) habit:

  • Pin not checked
  • CYPRES display not monitored
  • Wind and landing direction not verified
  • Exit sequence and -separation not questioned

The internet is littered with incidents that could have been prevented by a simple gear check.

Tip: Create yourself a small checklist, laminate it and put it in your helmet bag. If you always work through the steps in the same order, they will soon become part of your routine and can rarely be forgotten.

Example 2: You jump even though you are not fit to jump?

You feel sick or the party was long and the drinking level high. Nevertheless, you are sitting in load one, even knowing that you shouldn’t be jumping.
As an air sports pilot, the zero blood alcohol limit applies to us. Needless to say, we’re also not allowed to board the plane under the influence of other drugs or certain medication. Even tandem passengers must be completely sober, otherwise they are not allowed to jump.

Tip: Just stick to the ground. It is very rare that someone has ever suffered or caused a serious accident, who has had a good night’s sleep, then sits down at the side of the landing area with a cup of coffee or tea and sobered up in peace.

Example 3: You jump even though you are not fit to jump?

You are neglecting your emergency procedure drills or you’re not used to them anymore?

In case you

  • do not practice your emergency procedures regularly
  • Do not care much about safety-days
  • are not familiar with new equipment or
  • simply jump far too rarely

then the lack of practice will become normal for you. The German training manual speaks of this:

“The licence is issued for an unlimited period of time, but is only valid if there is sufficient ” practice” for self-responsible jumping”.

According to the USPA, the most common cause of skydiving-fatalities in the USA in 2017 was improper or missing emergency procedures. In April 2018, the “Parachutist” published an interesting article on this subject (see link #3 at the bottom of this article).
But also when you read the accident reports from Germany on the pages of the German skydiving association (DFV), you can draw conclusions about normalization of deviance in various ways.

What I’m trying to say is…

If we want to jump safely for many years, we have to have the appropriate discipline in everyday life. Of course accidents will still occur. But we should not simply accept that normalization of deviance is inevitable, but make a deliberate choice for “safety first”. A big step would already be taken if all of us – including the sky gods and the immortals amongst us – were willing to learn from the mistakes of others!

You do not have to make every mistake yourself.
Inform yourself, educate yourself and never stop critically questioning your own attitude as well as the attitude of your fellow jumpers.

What can possibly go wrong? I’m asking for your oppinion.

(Maybe a bit off topic but still somehow fits the topic)”It’s Murphy’s law”, “When it rains, it pours”, “Misery loves company”…

We constantly keep hearing these and other phrases. Why? Because they’re true.  Deviation from the established norm can lead to a concatenation of apparently minor misfortunes that will eventually end in an avoidable tragedy.

Here’s a story I have experienced similarly myself:

Lisa (*name changed by the editors, all analogies to real people and real actions are completely coincidental) has passed her license by the end of October, just before the end of the season.
In the skydiving school, there was always the same drop plane, familiar harnesses, a combination that fitted her well, no gloves, open helmets, jumping goggles and analogue altimeters. She is used to that, she knows all about it.

Meanwhile, she has now equipped herself with new, personal equipment: She has her own rig with a brand new parachute, of course one or two sizes smaller than the student’s parachute in the skydiving school. She has also bought a dytter, a digital altimeter, a custom made suit, nice warming gloves, cool polarized sunglasses and of course a full visor helmet.
On a cold, sunny November day, a good four weeks after the end of the season at her home drop zone, she is now heading to the PINK boogie near her hometown.

Lisa has never jumped out of this plane before and is very excited.

The new harness fits tightly because she is wearing ski underwear underneath the jumpsuit. The gloves are definitely a good idea at minus 25 degrees at 4000m and the full visor helmet should protect her face from the unfamiliar cold. The sunglasses should not be missing, of course, because the autumn sun stands low and is very blinding.

What can possibly happen? What chain of misfortunes could occur here, and where could it lead to?

We appreciate your thoughts! Discuss with your friends at the dropzone, comment on our facebook-page or leave a message via our contact form.


#1: Article “Normalization of Deviance – BEWARE!” by Lesley Gale, Skydive Mag, May 2018 

#2: Book “The Challenger Launch Decision”

#3: Article “Malfunction, Malfunction, Malfunction – the 2017 Fatalaty Summer” , Parachutist, April 2018

#4: This blogpost in German, January 2020

#5 Read Jacky’s classroom talk (1)

#6 Read Jacky’s classroom talk (2)

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