CHIEF WARRANT OFFICER 3 CHRISTOPHER PERKINS
G3, Aviation Mishap Investigator
U.S. Army Combat Readiness Center
Fort Novosel, Alabama
Spanish-American philosopher George Santayana wrote, “Those who cannot remember the past are condemned to repeat it.” This aphorism is true of Army aviation. Mishap investigations rarely uncover new contributing failures. Nearly every mishap is the result of a combination of the same errors that contributed to a previous mishap.
Statistically, eight or nine out of every 10 mishaps are attributable to human error. Of the aviation mishaps the U.S. Army Combat Readiness Center (USACRC) investigated between 2017 and 2022, the No. 1 recurring finding was the failure to follow procedures correctly. The most common latent factors were overconfidence, complacency, fixation, inattention, confusion and misperception of the changing environment.
The Army demands competent and confident personnel, so identifying and correcting overconfidence and complacency isn’t as easy as telling aircrews, mechanics, air traffic controllers, fuelers, support personnel and staff to “just do better.” Overconfidence and complacency are defined by the self-belief that the individual can perform an action or task without reference to a procedure, in violation of a standard, or in a way that knowledge, experience or judgment cannot support. Often, this action occurs without consequence. When an action or decision has no negative effect, personnel normalize this behavior, this deviation from the standard.
Normalized deviance, overconfidence and complacency do not occur suddenly. Rather, they are accepted behaviors that develop over time. I believe most people make poor decisions with the best intentions. We do not exercise a lack of judgment expecting to fail. We make the wrong choices due to a lack of planning; inadequate resourcing of time, personnel and equipment; insufficient training; a lack of oversight and leadership involvement; personal insecurities; and an unrealistic expectation of performance. Overconfidence and complacency are often the resulting attitudes of a resistance to change; the failure to correct inappropriate, incorrect and unsafe practices; weak leadership commitment to the risk management process; and a lack of proper talent management.
There are behaviors and tools to help identify and combat complacency, overconfidence and normalized deviance. The primary method seems obvious: adherence to and enforcement of written standards and procedures. It is critical you accept that you and others will make mistakes. Identifying these mistakes and, more importantly, learning from them is essential to avoiding complacency and overconfidence.
Another method is to stop normalizing the acceptance of deviations from the standard, be it in yourself or others. This behavior rarely goes unnoticed. In our profession, silence is compliance. In the last four years, every Soldier lost to an on-duty rollover where the living space of the vehicle was not compromised was unrestrained. None of those Soldiers was alone in the vehicle. The other occupants observed that behavior and accepted it by saying nothing.
Take an objective look at yourself and your organization. If you need direction on where to start, the USACRC website hosts the Lessons Learned page, where previous mishaps are summarized, key facts identified, and recommendations made for prevention. Check it out at https://safety.army.mil/lessonslearned. A CAC login is required. The USACRC also offers an in-person Safety Assistance Visit (SAV) at no cost to your organization. The SAV teams provide relevant mishap trend analysis and mitigation strategies and an open forum for discussion, all which often highlight factors and concerns that exist within your own unit. For more information on scheduling a SAV, contact the USACRC G3 operations officer in charge at 334-255-1373.