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.

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.

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

Links

#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)