
Bedford and the Normalization of Deviance - Pete_D
http://www.rapp.org/archives/2015/12/normalization-of-deviance/
======
imh
> There are several factors which tend to sprout normalization of deviance:

> First and foremost is the attitude that rules are stupid and/or inefficient.

This is a great reason why to try your hardest to avoid implementing stupid
rules. When some rules are stupid and become ignored, other rules lose their
power.

~~~
ubernostrum
If you think the world doesn't contain a large number of people whose attitude
is that _they_ are smart enough to decide what to do for themselves, and all
the rules are made by stupid people, you have another think coming.

And blaming the rules for the behavior of those people is not the correct
position.

(see also: why the only thing many HN users know about G.K. Chesterton is the
fence thing)

~~~
imh
I'm sorry you read that into my comment, but that's not what I meant to imply.
I simply meant that there's a balance to keep in mind when making rules.

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airwebster
Corporate aviation is a very different place than Part 121.

It is cool to see the author point out that the Part 121 world has largely
insulated itself from the "corrosion" of the normalization of deviance. (And
that acknowledgement coming from people like us who chafe under the structure
and rigidity of 121, but still give a shit about actual risk mitigation.)

The topic is interesting since the "dark ages" mentality of so much of
corporate aviation is worth exploring as what stunts its growth, innovation,
etc. (And I'd extend that to Part 135 too.)

~~~
zaphar
For those of us who are not as steeped in the world of aviation can you
perhaps share what Part 121 and Part 135 are?

~~~
danielvf
Part 121 - Air carrier / Airline

Part 135 - Charter

Part 91 - Small and non commercial

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joe_the_user
This is interesting in that here "the normalization of deviance" describes
situations where behaviors that can be measured as objectively bad still wind-
up normalized through implicit group consensus.

That such deviance still happens suggests strongly that deviance around things
that are less clear and less likely to result in harm to the professional
would be even more likely to occur. The simplest example is anyone who faces
the public and is expected to give full service. It's easy for that to
breakdown when it isn't convenient. One can see this today in everyone from
bureaucrats to police officers.

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lobotryas
Nice startup idea in the article for anyone interested:

>A better model would be that of the FOQA program, where information from
flight data recorders is downloaded and analyzed periodically in a no-hazard
environment. The pilots, the company, and the FAA each get something valuable.
It’s less stick, more carrot. I would also add that this sort of program is in
keeping with the Fed’s recent emphasis on compliance over enforcement action.

------
olliej
What I don’t understand is why the gust lock mechanism is gated on not be
ingengaged vs being disengaged. The report goes into detail about having the
lock in an intermediate state, but if you actually made it so that the
throttle was gated at X% unless the lock was completely disengaged (eg
mechanically release the throttle lever only when the lock was latched into
the disengaged position)

IS there some mechanical/aircraft-related reason that such a lock isn’t
possible?

~~~
transmissible
Well, think about it this way: airplanes don't have differential gear boxes
that transmit power to the drive train in contact to the ground. In other
words, power on the ground is not delivered by the wheels.

This means the engines that deliver the thrust in the air, are also doing the
same work on the ground. The traction is delivered to the air, and the rolling
is all relative to to the thrust.

The manner of control for the power of the thrust isn't based on throttle
alone. There are a handful of factors that tie together, to generate force.

Just like stepping on the gas, when a car is in neutral, you can spin up the
turbines or propellers, without directing the air in such a way that moves the
aircraft. The pitch of the blades matters. Also, with multiple engines, thrust
must be synchronized, or the effect is a turn, and one engine could push the
plane in circles, if controlled improperly.

So, it's not like leaving the emergency brake engaged in a car. There are
other variables at work.

I think it's also a factor, that often enough, with complex machines created
to solve for a complex problem domain, leaving configurable items as
independent as possible prevents more footgun scenarios than it creates. When
quick thinking is needed in an emergency, to deal with real world forces in
play, systems are best designed so that in a proverbial sense, you can quickly
throw yourself at a problem, when stopping and thinking about a strategy might
take too long.

This is not to say that stopping and thinking carefully about strategy should
be skipped, but that when trouble finds _you_ , despite best efforts, and
seconds count, having the ability to skip checklists and improvise in the heat
of the moment _does_ represent a desireable pathway for saving throws.

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pdkl95
One of the most important talks I've ever seen is Richard Cook's "Resilience
In Complex Adaptive Systems"[1], in which he explains the fundamental abstract
mechanism that _causes_ the normalization of deviance.

[1]
[https://www.youtube.com/watch?v=PGLYEDpNu60](https://www.youtube.com/watch?v=PGLYEDpNu60)

~~~
tome
Related article by Richard Cook:
[http://web.mit.edu/2.75/resources/random/How%20Complex%20Sys...](http://web.mit.edu/2.75/resources/random/How%20Complex%20Systems%20Fail.pdf)

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pif
> Example: the boss in on board and we can’t sit here for several minutes
> running checklists;

If your boss does not notice that the aircraft stood idle for too short a
time, and he doesn't fire you straight away, than the culture of safety did
not permeate your company enough.

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donbright
Does it really matter if you know you operate in an environment where deviance
is normalized? To me, it seems like realizing that you are in a cult. You
aren't going to change the cult behavior because you aren't going to change
human nature.

~~~
mannykannot
At the very least you can avoid joining the cult, and if enough people
understand what's happening, they can do something about it.

------
tome
Atul Gawande's appointment yesterday continues to echo around HN.

