Risk Management Magazine

As the cotter pin began to yield to the technician's efforts, an unforeseen consequence arose. In the heat of the moment, the technician underestimated the amount of force required to dislodge the pin completely. With a sudden and unexpected release of tension, the cotter pin broke free from its moorings, propelled by the force exerted by the technician.

It was a typical early summer day at Abu Hammad Air Base, Egypt, located in the Nile Delta northeast of Cairo. I was assigned as an AH-64A maintenance test pilot (MTP) and adviser to the Apache Technical Assistance Field Team. Despite the challenges of English as a second language for my Egyptian counterparts, I thought I had a good handle on how the local pilots expressed themselves. I was wrong.

The true danger of normalizing deviance lies in its subtlety. Initially, deviations might seem minor and inconsequential. Examples include skipping a procedural step due to a time crunch, deferring a minor maintenance procedure because "it's never caused a problem before" or bending the rules on driver training due to competing priorities.