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establish whether such processes or mechanisms did indeed
underlie the manifested errors. Then, based on this relatively
weak basis, they must evaluate whether the error management
techniques reportedly used by operational personnel
did indeed prevent the escalation of errors into a system
breakdown.
1.2.6 Second, and most important, incident reporting is
vulnerable to what has been called “normalization of
deviance”. Over time, operational personnel develop informal
and spontaneous group practices and shortcuts to
circumvent deficiencies in equipment design, clumsy procedures
or policies that are incompatible with the realities
of daily operations, all of which complicate operational
tasks. These informal practices are the product of the
collective know-how and hands-on expertise of a group, and
they eventually become normal practices. This does not,
however, negate the fact that they are deviations from
procedures that are established and sanctioned by the
organization, hence the term “normalization of deviance”. In
most cases normalized deviance is effective, at least
temporarily. However, it runs counter to the practices upon
which system operation is predicated. In this sense, like any
shortcut to standard procedures, normalized deviance carries
the potential for unanticipated “downsides” that might
unexpectedly trigger unsafe situations. However, since they
are “normal”, it stands to reason that neither these practices
nor their downsides will be recorded in incident reports.
1.2.7 Normalized deviance is further compounded by
the fact that even the most willing reporters may not be able
to fully appreciate what are indeed reportable events. If
operational personnel are continuously exposed to substandard
managerial practices, poor working conditions
and/or flawed equipment, how could they recognize such
factors as reportable problems?
1.2.8 Thus, incident reporting cannot completely
reveal the human contribution to successes or failures in
aviation and how remedial strategies can be improved to
enhance human performance. Incident reporting systems are
certainly better than accident investigations in understanding
system performance, but the real challenge lies in taking the
next step — understanding the processes underlying human
error rather than taking errors at face value. It is essential
to move beyond the visible manifestations of error when
designing remedial strategies. If the aviation industry is to
be successful in modifying system and individual performance,
errors must be considered as symptoms that
suggest where to look further. In order to understand the
mechanisms underlying errors in operational environments,
flaws in system performance captured through incident
reporting should be considered as symptoms of mismatches
at deeper layers of the system. These mismatches might be
deficiencies in training systems, flawed person/technology
interfaces, poorly designed procedures, corporate pressures,
poor safety culture, etc. The value of the data generated by
incident reporting systems lies in the early warning about
areas of concern, but such data do not capture the concerns
themselves.
Training
1.2.9 The observation of training behaviours (during
flight crew simulator training, for example) is another tool
that is highly valued by the aviation industry to understand
operational human performance. However, the “production”
component of operational decision making does not exist
under training conditions. While operational behaviours
during line operations are a compromise between production
and safety objectives, training behaviours are absolutely
biased towards safety. In simpler terms, the compromise
between production and safety is not a factor in decision
making during training (see Figure 1-2). Training
behaviours are “by the book”.
1.2.10 Therefore, behaviours under monitored
conditions, such as during training or line checks, may
provide an approximation to the way operational personnel
behave when unmonitored. These observations may
contribute to flesh out major operational questions such as
significant procedural problems. However, it would be
incorrect and perhaps risky to assume that observing
personnel during training would provide the key to
understanding human error and decision making in
unmonitored operational contexts.
Surveys
1.2.11 Surveys completed by operational personnel
can also provide important diagnostic information about
daily operations and, therefore, human error. Surveys
　
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