‘RECOVER!’ came the shout from the back seat of my Tornado GR4 combat jet but it wasn’t necessary – I had already started to yank back on the controls as hard as I could!
Our 25 tonne fuel laden bomber was now a treacherous 40 degrees nose down and shuddering madly as the airflow violently separated from the wing due to my impossible demands.
As we broke through the base of the cloud, my Head Up Display was suddenly filled with a sickening amount of earth and fields.
This was bad.
The Ground Proximity Warning System sounded.
‘WOOP, WOOP! – PULL UP, PULL UP!’
‘7, 6, 5 – that’s 400 ft Tim!’, called my Weapons Systems Officer.
We were well outside ejection seat parameters and we both knew it.
How had I got us into this mess?
Yes, sometimes you just have to stop.
And that can be very hard indeed, especially when you have been doing something for so long that it has become routine.
For most of us it might be societal addictions such as smoking, drinking, drugs, gambling – things that have now become normal in your life but aren’t doing you any good.
For others it might be work habits or just ‘things you do’ that, over time, have become routine and are now hard to change.
Sometimes, though, it can be a lot worse.
I recently learnt of a flying accident that so appalled my colleagues and I that it generated a discussion about if sometimes, what is described as an ‘accident’, should actually be defined as something that was more intentional.
‘Accident (noun) – An unfortunate incident that happens unexpectedly and unintentionally, typically resulting in damage or injury.’ – Oxford English Dictionary
The ‘accident’ involved a Gulfstream IV business jet that crashed in Bedford, Massachusetts in 2014 after the experienced crew attempted to takeoff with the gust-lock engaged. The gust-lock is a device that locks the controls to prevent damage from the wind whilst the aircraft is parked. The take-off was rejected at a very late stage which meant that the aircraft departed the end of the runway and broke apart with the ensuing fire killing all onboard.
The report’s Executive Summary concluded that the probable cause was the crew’s failure to perform a check of the flying control surfaces before take-off, their attempt to take-off with the gust-lock applied and their delayed actioning of the rejected take-off when they realised the controls were locked.
Contributing factors included the flight crews habitual non-compliance with checklists. In fact five checklists had not been completed and it had become standard practice within the organisation to not do them.
If the checklists had been done the gust-lock would have been removed prior to engine start and a full and free check of the controls would also have been completed.
To people who fly professionally, however, it is obvious that the report implies that the accident was caused by a theory called the ‘Normalisation of Deviance’.
This term was first used by sociologist Diane Vaughan in her book on the Challenger Shuttle disaster ‘The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA.’
‘Social normalization of deviance means that people within the organization become so much accustomed to a deviant behaviour that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety.’ – Diane Vaughan
The longer it goes on within an organisation, the more people become accustomed to it. People on the outside see it as abnormal but within the organisation it becomes accepted as everyday practise.
Due to the large size of some organisations it can be insidious and can also end up becoming more entrenched.
In 2003, Diane Vaughan was invited to join the Columbia Accident Investigation Board and was duly able to demonstrate that NASA had not learnt from the earlier Challenger accident and had replicated its risk acceptance and slid towards normalisation of hazardous operations.
‘But after getting deeper into the data, it turned out the managers had not violated rules at all, but had actually conformed to all NASA requirements. After analysis I realised that people conformed to ‘other rules’ than the regular procedures. They were conforming to the agency’s need to meet schedules, engineering rules about how to make decisions about risk.’ – Diane Vaughan on internal failings at NASA.
NASA had formed and complied with its own expectations that were being slowly eroded as the need to get the shuttle flying again became more urgent – we can all see how this can happen.
As in the Gulfstream accident report, the normalisation of deviance often results in an erosion of competency in which a culture of safety is slowly and gradually worn away.
It was something that I was acutely aware of when I was a Senior Supervisor on the largest fast-jet squadron in the RAF.
Because a lot of my senior instructors were leaving the Squadron at the end of their tours, the temptation was to qualify less experienced instructors to teach the more complex phases, but much earlier than we had historically been doing.
And this caused us a problem.
If we didn’t qualify the junior instructors it would put excessive workload onto the experienced guys and increase the risk of an accident through fatigue. But if we did rush to qualify the junior instructors then the risk of an accident would be because of these newly qualified instructors’ inexperience.
It wasn’t exactly a ‘win – win’ scenario.
Luckily we had external agencies that we could turn to for guidance such as the RAF’s Central Flying School (CFS) and psychologists at the RAF Centre for Aviation Medicine (RAFCAM) and in the end, a compromise was found.
But sometimes it’s too little, too late.
In 2011 two of my friends were killed in flying incidents whilst serving with the Red Arrows Display Team. At the time, due to my background as an experienced Hawk T1 pilot (the same aircraft as the team flew), I was ordered to be on the Service Inquiry Panel and to be a Subject Matter Expert (SME) assisting in writing the final report.
The incident I investigated was that of a friend of mine who had been killed whilst he was attempting to land after a display in Bournemouth. Although we found that the reason he crashed was predominantly medical, our report highlighted many areas where the Squadron was suffering from the ‘normalisation of deviance’.
You see, the ‘normalisation of deviance’ is not only found within large organisations but also in tightly knit, small, unique units such as display teams and Special Forces units.
This is because it is difficult for someone outside of these small units to have gained the experience and knowledge from within and so incredibly hard to understand if what the unit is doing is, indeed, ‘normal’.
I once spoke to a member of a unit tasked with assessing flying standards across all RAF squadrons and he told me that, when assessing a Red Arrows pilot, he found himself upside down at 100 ft over RAF Scampton’s runway in formation with two other jets only a couple of feet away.
How on earth was he supposed to know if this was normal?
He couldn’t and he would have to use his own experience coupled with the advice of the team.
I once knew a Flight Commander on another squadron who felt that his men were ‘above’ external assessment and he alone should regulate and evaluate them.
He was wrong.
It is true that sometimes assessment has to come partly from within the units themselves but external regulation and oversight should never be rejected.
Think of the global financial crisis of 2008 when the economy collapsed because the banks hadn’t been properly regulated because they convinced the authorities that they could do it themselves.
Look at it as someone you know telling you that you are developing a bad habit.
We’d all welcome the advice even if we didn’t actually like it.
You see, the ‘normalisation of deviance’ can also be found with the individual.
Take alcohol and drug addiction. Once you start, it quickly becomes normal and often, in extremis, there is no other normality that can be remembered.
Once in a while, though, it just leads down a path that ends up with someone doing something that is just plain stupid.
That was me when I almost crashed a Tornado GR4 in Belgium in the mid-2000s.
I was a confident young front-line pilot and had been sent to undertake a multi-national flying exercise in northern Europe. We had two jets and the agreement between crews was that you keep the jet you were given, meaning no stealing jets – if yours breaks then you stay on the ground until it’s fixed.
It was a good plan.
Right up until mine broke.
We had been doing really well on the exercise. As a pair of bombers we had hit all of our targets and hadn’t been shot down by the ‘red air’ aircraft who were playing the enemy. So much so that, at the start of the second week, we were being purposely targeted so that the ‘enemy’ could claim that they’d shot down all of the nationalities.
But in the second week only one Tornado got airborne and it wasn’t mine.
Our jet had a problem with the undercarriage or landing gear – it wouldn’t lock up under normal flight conditions; the wheels couldn’t be stowed away.
The engineers had found significant and unfixable wear to the mechanical uplock. It would only lock up under 0g and this would mean that I would have to bunt the aircraft, nose down, towards the ground whilst selecting the gear ‘up’.
I spoke to my Weapons System Officer (WSO) and we agreed to give it a go.
We got changed into our flight gear and, whilst the main exercise traffic were playing war over Northern Germany, we got airborne to try our engineer’s theory.
I climbed the jet to 5,000 ft, pulled the nose up to 40 degrees, pushed to 0 g and selected the gear up. It takes about 10 seconds for the gear to travel and it has a normal limiting speed of 235 kts which we soon realised was not enough as we ended up 30 degrees nose down and very close to over-speeding the gear!
We looked at the Flight Reference Cards again; we would have to use the Never Exceed speed of 250 kt.
Normally using the Never Exceed speed requires special approval but this was urgent so we felt that we could justify approving it ourselves.
We managed to get a few figures and parameters together and felt quite happy that, if we were careful, we could probably continue with the exercise the next day.
We talked through our plan with the engineers and our buddies in the other Tornado and it all seemed quite reasonable.
Until the following morning.
The cloud base was now only 4,000 ft and filled in up to 20,000 ft – we only had a limited space to perform the manoeuvre. If we managed it then we could carry on with the sortie, if not we’d have to burn 5 tonnes of fuel before we could land.
We got airborne, staying low with full reheat selected, then at 200 kts I pulled up to 40 degrees nose high, selected the flaps up and just below the cloud base, I pushed.
I grabbed the gear handle and moved it to ‘up’ – ‘Come on, Come on!’ I thought as the nose of the 25 tonne jet in full power slowly fell through the horizon!
I brought the throttles back to idle. At slow speed the big jet didn’t manoeuvre very well and if the nose dropped too far it would not recover before we hit the ground.
The gear was up and locked and as I brought the engines back up to full power I raised the nose to a climbing attitude. We had loads of time, we hadn’t even gone below 2,000 ft!
It had worked.
Over the next few sorties we carried out the same procedure. We even managed to convince the Air Traffic Control tower that what we were doing was normal!
But they knew it wasn’t and people were starting to ask questions including an American F-16 pilot who was also on the exercise.
‘Hey, what d’ya crazy guys doing with that ‘roller-coaster’ manoeuvre on take-off?’ he asked over some evening beers.
‘The gear won’t lock-up unless I unload the ‘g’.’ I said.
‘Oh, right – just looks really unusual in such a big jet especially with all that fuel onboard!’ he said.
I just smiled, embarrassingly.
The next couple of trips were also uneventful and our ‘roller-coaster manoeuvre’ became our normal way of departing the airfield.
I had been asked to go and see the Programme Director and, as I was certain that it must be about our ‘roller-coaster’ departures, I was doing everything I could to avoid him.
On the last day of the exercise the weather was worse than any we had experienced in the previous two weeks but it was critical that we got home else we’d be stuck in Belgium for another weekend.
At the morning briefing we found that we had a cloud base of just 1,000 ft – the lowest yet and we would have to be very careful about getting the gear up today!
I got us airborne and, again, we stayed low. At 200 kts I pulled the nose up as hard as I could but I only really managed to get about 30 degrees before we entered cloud – this was new!
I started the bunt, leaving the engines in reheat to help hold the 0 g I needed.
‘Come on gear!’ I heard my WSO call, followed quickly by ‘That’s 1,200 ft Tim.’
We were 20 degrees nose down.
‘COME ON!’ I shouted.
This was looking tight.
‘RECOVER!’, came the call from the back seat.
The jet was now 40 degrees nose down and as we broke the cloud I could see that we were in a very bad place.
We were low on energy and the nose was rising too slowly to recover the aircraft before we would hit the ground.
The Ground Proximity Warning System sounded.
‘WOOP, WOOP – PULL UP, PULL UP!’
‘7, 6, 5 – that’s 400 ft Tim!’, called my WSO.
The jet was shuddering against my demands, it just didn’t have the performance to pull out of the dive.
The cockpit was silent. To make things worse, due to our high rate of descent, we were well outside of any ejection option.
I quickly selected full flap and slats to increase the lift over the wing.
The sudden increase in lift meant that the nose started to pitch faster towards the horizon.
A bad picture was starting to look better.
Eventually I levelled the jet at around 2-300 ft above the ground and gradually I climbed us back up into cloud.
The gear had never locked up. It was going be a long, and a very quiet, journey home.
I was an experienced pilot but in the bracket where my over-confidence could well have been my downfall. The longer we’d continued performing the manoeuvre the more confident we’d become at doing it.
We had convinced ourselves that the rule breaking was for the benefit of the exercise and that what we were doing was essential.
But I’d almost destroyed a £50 million aircraft.
My actions in performing a zero ‘g’ bunt after take-off, in order to secure the gear, as outside of the rules as it was, had become the normal way to get airborne – I thought that what I was doing was right.
But I was wrong.
We were lucky that day but, just as my own personal deviance from normality had early warning signs, they are also there in all of the examples I’ve talked about.
- In the Red Arrows there had been accidents before in 2008 and 2010 with the loss of two aircraft. The squadron had a very unique way of operating and performed at a level that was exceptionally hard to assess to those outside of its culture.
- NASA had lost the shuttle Challenger, in 1986, through engineering complacency and had carried its flawed risk culture through to the Columbia missions and the loss of the shuttle on its return to earth in 2003.
- It is well known that jet pilots start with a bag of luck and start to fill a bag of experience – most accidents happen around the 700 flying hours mark. When I almost flew into the Belgium landscape 10 years ago, I had 650.
‘The trick is to fill the bag of experience before you empty the bag of luck.’
Before you try and change the world just have a look at the foundation from which you are starting it from.
Is it sound?
Have you significantly deviated from your own normality?
I say yours because everyone is different. We all have our own standards but, in all honesty, we often fall below them.
So, one thing at a time.
Let’s get the playing field level before you mark out the pitch.
Maybe just concentrate on quitting the cigarettes before you decide to buy the £50 per month gym membership. Or stop the crisps and chocolates before you commit to the full Slim Fast plan.
You know why the they tell you to put on your own oxygen mask first before helping others when flying out on holiday?
Because if you don’t take care of yourself first, you’re no help to anyone.
Take time for yourself, it’s not easy but you need to do it.
When I line my jet up on the runway I will always check that I have full and free controls, that there are no other aircraft on the final approach that might land on top of me and that the runway ahead is clear.
I also check that I have the correct flap selected and that my ejection seat is ‘live’.
I make sure that I have the fundamentals of flight secured before I go and attempt it.
Then, if I take a bird into the engine and throw a compressor blade on take-off, well, at least I have given myself the best chance of dealing with that eventuality.
Ask yourself, ‘What am I doing that is stopping me from being who I want to be?’
Now you can just concentrate on getting back to the fundamentals of ‘You’.