VIOLATIONS OF RULES AND PROCEDURES

VIOLATION OF RULES AND PROCEDURES

1.                     The only fatal accident involving C-17 Globe Master took place on 28 Jul 2010 while practicing for an upcoming Air show. The profile consisted of a maximum performance climb to 1500 feet AGL followed by an 80/260 reversal turn and finally descending to 500 feet AGL for a high speed pass. The pilot deviated from the profile significantly and operated the aircraft beyond the safe limits leading to deep stall and killing all on board. The deviation started from the take off itself where as against the targeted climb out speed of 133 knots the highest airspeed attained during climb was 107 knots. Thereafter, the aircraft was leveled out at 850 feet AGL instead of the prescribed 1500 feet. The first left turn was made at an angle of bank of 57 degrees against the recommended 45 degrees. The flaps were selected up by Copilot without any call. The out bound heading was flown for 7 seconds (less than half of what was required) and the second turn of the 80/260 degrees reversal turn was initiated with a bank angle of 53 degrees. Copilot initiated the slat retraction during the turn at a speed of 188 knots as against the minimum slat retraction speed of 193 knots. After 5 seconds the stall warning activated but the pilot continued the turn using full right rudder which increased the aircraft bank angle to 62 degrees. The g increased to 2.4 and the aircraft stalled and impacted ground with 63.6 degrees bank and 16.9 degrees nose low at a speed of 184 kts. The Inquiry blamed the pilot for the accident. The report read “The board president found clear and convincing evidence that the cause of the mishap was pilot error. The mishap pilot violated regulatory provisions and multiple flight manual procedures, placing the aircraft outside established flight parameters at an attitude and altitude where recovery was not possible. ……. In addition to multiple procedural errors, the board president found sufficient evidence that the crew on the flight deck ignored cautions and warnings and failed to respond to various challenge and reply items.”      The inquiry brought out that the Captain had gradually manipulated the standard profile to enhance the air show performance. He planned and regularly flew 60 degrees of bank for the 80/260-degree maneuver with full rudder to minimize the turn radius and displacement from crowd. In previous performances, he continued to execute his 260-degree reversal turn despite lengthy stall warnings. He also routinely instructed and planned to ignore stall warnings during aerial demonstrations and flew numerous demonstrations with the stall warnings active and without incident. The Captain had a reputation of being an extremely precise and knowledgeable aviator. His extensive experience as a simulator instructor and his 3,251 total C-17 hours garnered him the utmost respect from squadron leadership and his peers. They also held his instructor abilities in the highest of esteem. Because he was an accomplished aviator, leadership allowed him to operate independently with little or no oversight.

2.         Almost similar accident took place in 1994 where a B-52 was flown into ground killing all on board. Here too, the sortie was a practice for an upcoming air show. The Captain was highly experienced and senior pilot with rich experience of such flights. While coming in to land after the practice the aircraft was asked to go around because of another aircraft on the runway. The Captain did an overshoot and immediately got the ac into a tight 360 degree slow speed turn with full flaps. It attempted a left turn around the control tower at only 250 feet AGL (span of B-52 is 185 feet). At three quarters of the way through the turn the ac banked past 90 degrees stalled and crashed. There were no survivors. In the sortie which lasted 18 minutes virtually every maneuver performed by the Captain exceeded operating limitations of B52 and violated rules and regulations. The Captain was notorious for his reckless flying. Many crew members had asked not to be assigned to fly with him due to his dangerous approach to flying. He was involved in many cases of dangerous flying but the senior officers, in spite of full knowledge of such cases, preferred to remain silent. His character has been immortalized by Tony Kern through his case study in the book ‘Darker Shades of Blue’. The label ‘Rogue Pilot’ aptly fits the person piloting the B-52. Tony Kern ascribe this intentional oversight to his blatant disregard to violation of SOPs as also due to ‘Failed leadership’ where the leadership just failed to domesticate a wild beast let loose. The inquiry revealed that the pilot habitually disregarded rules and regulations and flew unsafely. He had grossly violated the regulations in many aerial demonstrations in presence of many senior officers. It was clear that it had become habitual and normal for him to intentionally break rules and regulations.

3.         It is a paradox that the very qualities that help in avoiding accidents did, in fact, contributed to these two unfortunate accidents. Experience, knowledge and practice combined with the fact that they had been routinely doing such demonstration flights pushed the two pilots into ‘complacency’ where they failed to see the dangers in the path they were treading. Both wanted to make the demo more ‘electrifying’ for the audiences. They also, in all probability, felt that their professional status justified breaking the SOP which is after all made keeping in mind a ‘very average’ person. Both regularly flouted norms and regulations and the Organization tolerated/accepted these deviations which gradually became normal not only for the pilots but to the higher leadership also. It is interesting to note, though, the contrasting reasons for the senior hierarchy not to act against these two errant individuals.  In one case, B-52 pilot, the person was a rogue, in disciplined and bully and every one kept waiting for him to retire or go out in natural process. No one wanted to bell the cat. The other, C-17 pilot was hailed as a well respected and knowledgeable professional and hence no one checked him. Both broke the cardinal principal of keeping the aircraft within flight envelope. There are records to indicate that they both have been appreciated, by the higher formations, for many sorties where they have broken the rules and procedures. Initially they would have been very careful while performing these difficult and over the edge maneuvers but slowly it became a normal thing for them.  Both pilots intentionally violated laid down rules and procedures regularly and drifted everyone including themselves into what is called ‘normalization of deviance.’

4.         The term ‘Normalization of deviance’ was first used by Diane Vaughan in her book “The Challenger Launch Decision: Risky Technology, Culture, and Deviance at NASA.” She writes ‘Social normalization of deviance means that people within the organization become so much accustomed to a deviant behavior that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety. The longer it goes on within an organization, the more people become accustomed to it. People on the outside see it as abnormal but within the organization it becomes accepted as everyday practice. Due to the large size of some organizations it can be insidious and can also end up becoming more entrenched.” Such non compliance which gradually drifts into normalization is not uncommon in aviation. A 1990 NASA study reported that two out of six airline crews they observed on one particular wide-body airplane type neglected to perform all flight phase checklists during a flight. Line operations safety audit data from more than 20,000 airline flights conducted between 1996 and 2013 revealed that 49% of such flights involved at least one instance of intentional noncompliance. It’s a well known fact that flight crews continue 97% of unstable approaches to landing, which is against most airline policies. An NTSB study of flight crew-involved in major accidents that occurred between 1978 and 1990 found that 24% of the errors made in these accidents were procedural errors, making it the most common category of errors. The procedural errors identified in the study included numerous examples of procedural noncompliance. Of the 10 takeoff accidents examined, for example, 6 involved uninitiated or inadequately performed checklists that were causal to the accident. This noncompliance resulted in attempted takeoffs with miss- trimmed control surfaces (two accidents), flaps not extended (two accidents), incorrect use of engine anti-ice systems (one accident), and locked controls (one accident). A study indicates that intentional non compliance occurs between 40 to 60 percent of the flights. Once such shortcut is carried out multiple times without any adverse outcome it becomes an acceptable practice and without anyone discerning, it replaces itself as normal.         We have to just look around to identify such latent acts which are not permitted but somehow becomes norm. They lie dormant and come to lime light only when some accident happens.

5.         Violations, though, are not always associated with indiscipline and it is simply naïve to assume that if a pilot is not following procedure it is because he is lazy, defiant, unprofessional or just a bad pilot. Many a times it happens due to the manner in which procedures are created, communicated and enforced. Procedures may be difficult to perform and may impose excessive cognitive demands. At times the procedure simply does not make sense or are simply too cumbersome necessitating a short cut. Such rules are initially defied by few to be followed by others and gradually normalizing it in the system. Organization and supervisors must accept responsibility when it comes to procedural non compliance and must understand that there are indeed bad procedures. If rules and checklists and regulations are difficult, tedious, unusable, or interfere with the goal of the job at hand, they will be misused or ignored. Existing Organizational culture has a large influence on attitude of people towards rules and regulations. Giving primacy to getting the job done rather than how it is done sets the stage for short cuts, bends and tricks.  The violators, in such Organization, may in fact be working with best intentions genuinely believe that bending the rules are required to get the task done. Task accomplishment syndrome prompts supervisors who are directly responsible for operations to take short cuts to achieve the tasks. In civil parlance it is the management pilots who are more likely to be involved in such cases. Supervisors, at times, tend to reward the violators by looking away from their violations in the light of task achievement as also appreciating them thus turning the rewarding system upside down. 

6.         Procedural non compliance has been cited as a contributing factor in majority of the accidents.       Procedures, rules and SOPs are designed to protect us from inherent human limitations that affect everyone. When we violate procedures these safeguard break down. When we do this habitually it is only a matter of time before everything catches up. Supervisors have an important role in curtailing this hazardous attitude by first setting right examples and secondly in scrutinizing the environment for latent seeds of violations. They have to be watchful of slow drift into normalization of deviance where not following procedures and taking short cuts becomes an acceptable practice. The slow drift into normalization can be best understood by the analogy of fable about the ‘Boiling Frog’. If a frog is put in a pot of hot water it will instantly jump out. However if it is put in normal water which is then very gradually heated to boiling point the frog will not perceive any danger and would be boiled alive. The slow changes are hard to be perceived even if they are dangerous.

CONCLUSION

HEINRICH’S ACCIDENT PYRAMID H. W Heinrich, an industrial engineer, in 1931 developed a model, based on his extensive research into industrial accidents. He concluded that in a workplace, for every accident that causes a major injury, there are 29 accidents that cause minor injuries and 300 accidents that cause no injuries.  The pyramid has found wide acceptance in the aviation world where it is reworded as, ‘One major accident precedes 30 incidents and 300 violations’.  Both pilots had reached more than their share of violations and incidents which is easy to calculate. The mishap sorties, which had not been much different from the ones they have been routinely doing, had violations at every phase and moment of the flight.