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‘Normalisation of Deviance’

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Image: Google Earth/ATSB

The Gulfstream 695A was being flown on a photo mission associated with the mapping of fire zones in Queensland, Australia, when air traffic controllers lost contact with the pilot. Multiple attempts to reestablish radio contact succeeded briefly before contact was lost again. Soon afterward, the Gulfstream entered a descending turn and crashed to the ground.

The pilot and two camera operators were killed, and the airplane was destroyed in the Nov. 4, 2023, accident 55 km (30 nm) southeast of Cloncurry, the Australian Transport Safety Bureau (ATSB) said.

In its final report on the accident, the ATSB said the airplane “had a long-term intermittent defect with the pressurisation system” and that company management knew about the problem and attempted to have it corrected. Nevertheless, the report added, management “did not formally record the defect, communicate it to the safety manager, undertake a formal risk assessment of …

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