Absence of Procedure

Absence of Procedure

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Definition

Absence of procedure is condition for which no prescribed procedure exists.

Description

Historically, many different investigation agencies have identified deficiencies in standard operating procedures (SOPs) as a common contributing causal factor in aviation accidents and incidents. Some of the most cited deficiencies involving front line aviation personnel were identified as

  • Non-compliance with established procedures;
  • Non-existence of established procedures

The International Civil Aviation Organisation (ICAO) has long recognised, through provisions in its standards and recommended practices (SARPs), the importance of following SOPs for safe flight operations. For example, amendments to ICAO Annex 6, Operation of Aircraft, establish that each Member State should require that SOPs for each phase of flight be contained in the operations manual used by pilots.

SOPs are usually laid down in different forms:

The SOPs enable the pilots and controllers to respond correctly in most types of normal, emergency or abnormal situation and are developed over a period of time after careful study of the situation, and are tested to ensure that they do not result in unintended and undesirable consequences. At the same time, the emergency sections of many SOPs note that a specific procedure cannot be written for every possible set of circumstances, especially in cases of multiple malfunctions that may or may not be interrelated.

Procedures, Lack of Procedure and Breach

Current and Available Procedure

Where established procedures exist, they should be followed unless exceptional, overriding circumstances exist.

Lack of Procedure

Where an established procedure does not exist, pilots and controllers should not attempt to find a procedure which resembles the one which is missing; following a procedure which was not designed for the existing situation may have unforeseeable and undesirable results. In the absence of an established procedure, pilots and controllers should exercise their judgment to the best of their abilities, based on experience, skills and knowledge.

Breach of Procedure

Occasionally, aviation personnel may intentionally choose not to follow an established procedure, or to omit certain actions listed in a procedure. This may occur because of negligence, ignorance, complacency, or overconfidence (“cutting corners” syndrome).

Alternatively, intentional breaches of procedure may occur because the procedure is not fit for purpose - in such a situation, pilots/controllers must raise the issue with management as soon as possible (see Inappropriate Procedures).

Unintentional inappropriate action sometimes occurs because the pilots or controllers are unaware of or cannot identify an appropriate procedure for the situation, or because of misinformed or wrong judgement.

Inappropriate Procedure

On occasion some operational procedures, for various reasons, become outdated and inappropriate. If the presence of (an) inappropriate procedure(s) is not obvious or detected, it may present operational risks.

Defences

  • Communicate – Stress the importance of following SOPs for the safety of flight. Periodic briefings and discussions regarding issues with certain procedures are likely to voice solutions at intra-organisational level.
  • Seek assistance – In case a proper procedure cannot be identified and, if time permits, seek advice from qualified personnel. Do not adapt procedures on a local level unless exceptional, overriding circumstances exist. When time allows, it may be possible to obtain assistance by referencing the lack of procedure to the necessary technical or operational department.
  • Alert of absence of procedure – Advise management of the scenario where the procedural gap exists; Communicate and alert colleagues and co-workers about the absence of procedure. Ask for strict and unambiguous guidelines, even if these guidelines are temporary, until the new procedure is defined. Periodic training and drills are likely to improve intra-organisation coordination.

Related Articles

Further Reading

ICAO

  • Preparation of an Operations Manual (Doc 9376).

FAA

  • FAR 121.133, Preparation of Manuals.
  • FAR 121.135, Contents of Manuals.

EASA

Flight Safety Foundation ALAR Briefing Notes:

Other

Categories
Human Behaviour, HF-AM, HF-AO, HF-ATM

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