Dec 20, 2015 – Normalization of Deviance

I experienced a form of normalized deviation while at Piedmont airlines. Their training department is aware of it, but not equipped to deal with it in terms of resources and a unified approach. New pilots are made aware of it, but those who haven’t experience it elsewhere may have a hard time learning to fly in two new ways.

The concept of Normalized Deviation first came to my attention through a blog that a friend referred to me. I believe the concept was originally defined in a book by Dr. Diane Vaughan discussing the Challenger accident and the launch decision that led to it. When I read about it, and several other takes on the concept, I was able to draw parallels with what I’d experienced at Piedmont.

Normalized Deviation, or the normalization of deviance, is defined as: “The gradual process through which unacceptable practice or standards become acceptable. As the deviant behavior is repeated without catastrophic results, it becomes the social norm for the organization.”

The application of Flows, Triggers, and Check-Lists is first introduced during your InDoc training at Piedmont. This is akin to a play of sorts – two crew members managing all stages of flight in a prescribed manner – many times a day – and doing it safely. First Officer candidates at this stage are learning mostly by rote, unless they have previous Part 121 experience. You read about it how a flight procedure should be done, are then tested based on your knowledge, and then proceed to apply it during flight training in the simulators. No confusion here – just do it the way you’ve been trained on the ground or your don’t pass.

In my case, I was very successful on the first time through and completed the training in the minimum time. From the time I joined Piedmont, it took only 6 weeks to hit the line as an FO. I didn’t accomplish this all by myself. My classmates all were supportive, and both of the Captain Upgrade candidates in the class guided me along. The most significant direct training and assistance, by a long shot, came from my sim Partner and friend, Calvin. He was one of the two Captain upgrade candidates at the time.

Calvin had been on the line for over 7 years as a First Officer by the time he upgraded, and had significant experience both in flying the line and getting through recurrent training. The last sentence holds a significance that is not obvious until you learn what I have – flying the line and getting through training are two different skills. You have to be able to do both.  Calvin was an invaluable resource for getting me through it my initial training. Getting myself back through training would teach me all about normalized deviation, but I’d be entirely on my own.

Throughout my interaction with the training department, I’d been warned not to pick up bad habits while out there flying the line. Fly standard all the time, is what they’d tell you, so when you come back you’ll have no problem.  In my mind, this was very similar to admonishments given in professional training elsewhere. You are told to stick to a standard and work hard to keep your peers moving in that direction. Standards are a good thing.

Keeping to standards makes sense in the electric utility space for safety; software development; and even engineering technique. It makes sense that it would also apply to aviation, and I’m all for having a standard way of flying. Professional recurrent training generally recognizes that standards inevitably erode in the field due to time constraints; cost cutting; etc. Recurrent training is intended to offset standards erosion by incorporating a review of where you are, coupled with renewed training and practice that re-establishes the base line performance. You get sent out with a renewed approach and a cleaned up style.

My exposure to Piedmont’s recurrent training was a new experience for me, in that it acknowledged the erosion but didn’t bother with corrective intervention. There was no open discussion of the differences that the training department knew was there in the line flying versus flying in the training department simulators. Time constraints required you were in and done, so this was a check-ride, pure and simple. At the end of my first experience, what I received on the way out the door was an admonition to come back in 6 months instead of a year. The reason given was that I was using check-lists improperly, and I wasn’t communicating to the Flight Attendant and Tower during runway emergencies as I should. Several other minor things, all related to standardization, were noted. All were true.

So, after 13 months of line flying where all the Captains were happy with my performance, Training was telling me I needed more practice cleaning up the non-standard items. I left there not fully understanding how to improve on the next go-around. I left not remembering anything about what I’d learned about triggers, flows, and check-lists and the appropriate order they were to be conducted in. I left without being retrained in how those things should be applied.

I consider myself a pretty smart guy, but I was having a bit of trouble trying to figure out why I was flying so well on the line, and the only folks critical of me were in the training department. Note: others in the same boat had figured all this out ahead of time, and gotten through. I missed the big picture and found myself with no time to recover. My bad, and I accept that. I could have done better.

TRIGGERS, FLOWS, and CHECK-LISTS: Triggers are events or a condition that initiates a Flow. The Flow is a memorized movement performed by either flight crew; generally involving a series of actions you’d like completed efficiently. The Check-List is generally performed after a flow to ensure that all of the key items have been completed.

In the training department, triggers are performed in a timely and efficient manner. On the ground, the Captain’s role is to always call for checklists at the appropriate time, or perform an action that is readily identified and can be used by the FO to start a flow. In the air, the Pilot Flying (PF) calls for the check-lists. Things are only done one way, and each identified checklist is preceded by a flow which is preceded by a trigger. Each trigger-flow-checklist pattern is an act in a play, and the actors are the Captain and the First Officer.

On the line, triggers are often muddled or completely omitted. You rush off the gate, and hurry to the hold-short line. The experience related to triggers on the line vary so significantly by Captain that an efficient FO generally acts on his own triggers. Only a few check-list calls follow the standard, and act as triggers. lows are performed when the perception is that they are needed, based on the Captain, and based on the tempo of the flight. Most Check-lists are always completed, but in a very few cases, some are omitted. Those omitted are done in your head if no one wants to hear it.

The experience, then, is that most line flying is non-standard. The exception is for brand new Captains, Training Captains, and check-airmen. For the inexperienced FO, you must learn two different plays and become two different actors if you are going to get through the training department readily.

Trouble comes when you realize a few things. You will only get to practice for one of those plays once a year, while the other play has 6 performances a day for the bulk of your existence. You will not be re-trained to the standard play, but will go right into a check-ride each time you are up for recurrent training. You just don’t know what you don’t know, until you do.

Just one month after my first recurrent training had asked me to come back in 6 months, I was suddenly given the chance to upgrade to Captain. Just before beginning sims, Bev was diagnosed with a serious health issue. She and I talked about it, and decided there was no sense in my pulling back now. We didn’t know enough at the time, and tests were still ahead. I pressed on. This is the point where the real learning on how to train at Piedmont began for me. This is when the big picture started to come into focus.

I returned to Toronto and the sleep deprivation I had been experiencing returned with a vengeance. The sim schedule was ridiculous and I was under more pressure than I’d experienced before. My first 3 sims were relatively easy and went well. The fourth sim added more tasks, and the cracks in my armor started to show. That is the point when the different plays in which I’d needed to perform differently became clear. I wasn’t used to getting triggers on the line myself, so I wasn’t providing any for the new guy. The criticisms I’d heard after my only recurrent check-ride now all of the sudden had meaning. Only now I had an almost insurmountable hill to climb that I hadn’t been prepared for, and very little time to do anything about it.

To make it to Captain, then,  I’d need to reconcile flying the line with flying in the training environment. I had to do this first from the right seat as an FO in my head, and recall what I’d been trained to do some 14 months ago. I needed to be an actor in a play I hadn’t been prepared for, and learn my new role as Captain at the same time. There was to be no help forthcoming, and no collaboration on weak spots. There was no time to sleep and certainly no time to act on this new understanding in order to prepare for the next lesson. I had to have known this before I got there, or otherwise figure it out on my own.

I think that with a bit of help and allot more sleep, I could have gotten through the upgrade process. By the first break in the brutal sim schedule, however, I had a pretty good idea that I’d be withdrawing. I was also pretty sure that I wouldn’t try to upgrade again until I got through training smoothly, which would take at least a year, even though I would be eligible to try the upgrade again in 6 months. I needed to be sure I could fly both ways as an FO before I tried again.

It is important to note that, had I not taken the upgrade opportunity, it could have taken me years to get to this point of understanding on my own. Instead, I now have the tools I needed to do this when I’m ready.

While home on my first break from sim training, I received a call from the head of training, where he reviewed the instructors comments to date, and asked me what I thought. I told him that what the instructor said was accurate, and that I was looking for some training to tune up the weak spots. He was direct, exceedingly negative, and unyielding. I took the hint and withdrew from Captain upgrade training immediately. I didn’t have their support before, and after this conversation, knew that I’d see nothing but additional obstacles in front of me.

I was studying in my den when the call came, and the relief I felt after withdrawing was palpable. It would be short-lived, however, as I’d soon see that this same department intended to put those same obstacles in front of me to make it as hard as possible to regain the right seat as well. Someone was making a point.

In early December, I re-qualified from the right seat with a sim check-ride down in Charlotte. I did very well with that, and received supportive comments from the instructor. I could tell he wondered why I was being given the third degree by his comments, and I said nothing. He knew I was stressed. He was compassionate, but never lenient. When the guy who made all the calls was unavailable to hear the results, the instructor did tell me that I had done well. He said I was safe and proficient.

I went to the lobby to await further details, and to hear the head of training’s reaction.

Later that day I heard from him, and the story that was relayed to me was significantly less positive than what I heard directly from the instructor. Clearly biased to the negative. I was told the instructor suggested that I needed one more check with an SOE ride (supervised experience) before I rejoined the line as an FO. While I think the explanation of who recommended the SOE was not accurate – it absolutely is the prudent thing to do for CYA and to ensure I had regrouped. I hadn’t flown for two months, so all of these checks made perfect sense. It just could have been handled differently. I had successfully rejoined the line as an FO in mid-December.

By this time, Bev’s follow-up exam showed her condition was more serious than first thought. The January schedule came out, and it had me away from home for 3 out of 4 weeks. I’d be away for Christmas and New Years as well, as expected, since I’d be returning as an FO on reserve.

So I started thinking. Another year before I’d try for the next logical challenge – Captain upgrade. Each month of that year with increasingly challenging schedules that keep me away from home just to experience flying. One or two chances to learn the training play during subsequent recurrent visits, and get that process down. No new challenges in that year, other than mastering two ways of flying.

I weighed all that against Bev and I wanting to play in our 60’s. We really want to do some traveling while our health allows it. I considered the fact that I’ve been incredibly blessed to be able to walk away from a lucrative career and have a bold and supportive wife encourage me to try flying for the regionals. She knew I’d be gone allot, and wanted me to keep going until I got tired of it.

All of the sudden it became clear that I’d be wasting the best years of our retired lives by continuing on this course. It suddenly made incredible sense to resign from Piedmont altogether, and make being home and time together a higher priority. I’d taken this as far as I wanted to, based on the commitment I was willing to make. I’d regained the right seat and was in good standing. It was time to move on.

IN SUMMARY: In my view, the non-standard flying issue is one that the training department should be working on as a means to provide an incremental safety improvement. Currently they acknowledge that it is a problem, and expect pilots to handle it on their own. This is not a safety crisis, rather an opportunity.

The timing of simulator schedules absolutely sucks. If you find you have an issue, you and your sim partner often have no time to work together to resolve any issues. Train to proficiency is a myth – you get a few chances at it, but very little training.

Overall – the flying done at Piedmont by the Captains and FOs is already incredibly safe and professionally executed. I’d send my family with these folks. They are professionals and I learned allot from them. Everything except learning to fly standard,

Finally – I acknowledge that I have limited, though valid experience in the airline industry. My perception is presented here, and this has been influenced by 35+ years of professional training in other industries. Aviation training departments are spread thin, short on funds and depth, and my experience was one result.

For my part, I was naive in some aspects and though working hard to prepare, didn’t spend that time preparing for the right things. Hopefully, new regional pilot candidates will get something from this and be able to use their resources to help them prepare with a better perspective than I.

Fly safe…..

Frank