1 Background and Introduction
Line operations in any airline are primarily procedure-driven processes. If the underlying procedures are well designed, appropriate and regularly followed, safety will be maximized. This briefing note provides a summary of considerations important to the assessment of the adequacy of aviation procedures. Use of the Procedure Assessment Tool (PAT), which is included in the OGHFA material, is recommended. This tool is designed to assist in understanding rule breaking and procedural noncompliance.
To assess procedural compliance, it is necessary for managers to ask themselves and employees the following questions:
- Do we know and understand the procedures?
- Do we need all the procedures?
- Are there situations in which it is impossible to apply certain procedures?
- Does the task itself encourage noncompliance?
- Is it possible to have a procedure for every situation?
- Are there alternatives to the current procedures?
For simplicity, this briefing note assumes that the generic term procedure covers both rules and the methods used to take actions as outlined in the rules. The PAT consists of a questionnaire and the explanation here of how to analyze the responses provided by the participants.
Violations are intentional actions or inactions that result in noncompliance with known rules, procedures or norms. There are several types of violations that can be deemed noncompliant with procedures:
- Unintentional violations arise from procedures that are impossible for people to follow, often because they are difficult to understand.
- Routine violations result from automatic and unconscious behavior. An employee may consider a violation as low-risk to himself/herself or the task. Violations are accepted by the particular work group as the normal way of conducting business.
- Situational violations are the result of workplace or environmental factors that make it difficult for the employee not to commit a violation. These factors include time pressure, lack of supervision, poor ambient conditions (e.g., light, noise), unavailability of equipment and insufficient staff.
- Optimizing violations occur when people try to make a task more exciting or interesting to impress others or to relieve boredom. These are common when people are involved in long periods of monotonous work, such as monitoring tasks, or when the rules are restrictive or outdated.
- Exceptional violations are rare occurrences that take place in very unusual circumstances (e.g., an emergency, equipment failure). They can be the result of a conscious decision to violate or an instinctive reaction to the situation.
2 Using the PAT to Assess Noncompliance
The PAT can help to assess potential risks from these types of violations by asking employees to indicate their level of agreement with a variety of statements. The level of agreement is indicated with a five-point scale ranging from 1 (strongly disagree) to 5 (strongly agree).
By looking at subsets of the responses to the statements, an organization can also assess the extent of noncompliance at a particular location or within a particular work group.
With more than one set of procedures in effect for a department or job, it may be necessary to use separate surveys that specifically address each set of procedures. Such surveys may be useful in identifying the exact procedures that need to be addressed.
The PAT provides an indication of the extent to which the respondents comply with the procedures in question. The first step is to gather the responses from those employees who participated in the survey relating to a particular set of procedures or a compliance issue. There are 45 items (statements) in the survey. An index of the risks due to noncompliance for each violation type can then be calculated as follows:
1. Sum the numerical responses for each item and divide by the total number of surveys completed. This will give you the mean rating for each item.
2. There are five groups (subsets) of items. The first four groups contain 10 items each, and the final group contains five items. Sum the mean ratings for each group’s items. For the first four groups (items 1-10, 11-20, 21-30, and 31-40), this will give you a score of between 1 and 50. For the fifth group, the sum must be doubled in order to get a score between 1 and 50.
High scores indicate problems with procedures. A score greater than 30 indicates that action is necessary to improve procedures or the processes governing them. Checking individual question scores or employee comments may clarify the nature or location of the problem.
3 Responding to Problem Areas
The PAT scores should alert you to problems with your procedures and the types of violations that are being committed. Solutions to some of the problems associated with procedural noncompliance are discussed below.
3.1 Unintentional violations (PAT items 1-10)
High scores on questions 1-5 suggest that the problem is with the procedures themselves. It is important that procedures are written from the employee’s viewpoint and are in a format suitable to the task. Where a series of actions is required, checklists are the best means for ensuring that the task is accomplished correctly. For other situations, a diagram may better represent the information.
High scores on questions 6-10 suggest problems with the distribution or knowledge of procedures and the training associated with them.
Check that existing procedures are correct, clear and not overly lengthy or complicated.
Check that employees are aware of the procedures and have been trained in their use.
3.2 Routine violations (PAT items 11-20)
High scores on items 11-20 indicate that employees believe the procedures are unnecessary or overly restrictive. If these beliefs are not correct, hazard awareness training may be necessary to inform employees of the necessity for the procedures.
If there is a better or more efficient way of doing the job, employees may feel they are justified in adopting the new way and not following existing procedures. Routine violations often allow the job or task to be performed in a way that is easier for the individual, and therefore the job is performed more quickly. Often, groups of employees develop alternative and sometimes more efficient practices that management may wish to recognize as correct. Rewriting procedures gives employees ownership of the procedures and will typically have a positive effect on compliance.
Before rewriting procedures, it is important to ensure that employees are aware of and understand existing ones. Check with employees to determine if alternative procedures or more efficient methods for completing a task should be used. It is important to check that existing procedures are not unnecessary or overly restrictive.
If there are too many procedures, reduce the number. This should limit the number of instances of noncompliance since there will be fewer procedures to be noncompliant with.
Ensure that people who use procedures know why they are written. Employees should know that procedures are written:
- For the safety of the work force.
- To improve the company’s profitability (and employees’ wages).
- To comply with national regulations.
- Not simply to protect management.
Provide an explanation of the need for a procedure by identifying the risks to personal safety. Avoid safety rules that represent “do's” and “don’ts” where the don’ts are punishable in some fashion.
Preventing routine noncompliance involves considering the need for each new procedure before it is introduced. Procedures should continually be updated to cover changing working conditions and new equipment. They should also be revised to prohibit actions implicated in some past accident or incident.
3.3 Situational violations (PAT items 21-30)
High scores on items 21-30 provide evidence of differences between what is required by the procedures and what is possible to achieve with limited resources. Situational violations arise because the situations in which people are asked to work are far from ideal. Noncompliance occurs in an attempt to complete the job given these constraints. Procedure enforcement may fail under these conditions if the supervisor feels that achieving goals or completing the job is more important than safety considerations.
Factors that promote noncompliance include time pressure, high workload, unworkable procedures, inadequate equipment, bad conditions, short staffing, and poor supervision.
Alternative or improved working methods or equipment should be considered if procedures specify the use of certain equipment or a certain number of people for a task, but the equipment and/or the people are unavailable.
Local solutions often are necessary because the factors promoting noncompliance are determined locally (e.g., operating “one man short,” a piece of important equipment has not been repaired or replaced).
In addition to providing support for procedural compliance, managers need to be aware of the effect of working conditions on individuals attempting to do their job according to the procedures
3.4 Optimizing violations (PAT items 31-40)
High scores on items 31-40 could reflect the desire to complete the task in a professional manner, but could also indicate the human weakness of “getting a buzz,” “having a laugh,” avoiding boredom or demonstrating skills to fellow workers.
Relying on procedures to control the behavior of highly skilled employees may only serve to reduce the efficiency gains made by employing and training such staff. It is often better to make the job more interesting by redesigning the task through job enrichment and flexible working groups. You can also redesign procedures and involve the staff in the writing and evaluation of the new procedures.
It may be necessary to avoid giving incentives that could lead to procedural noncompliance. Instead, use incentives for procedural compliance and safety, and avoid punishing noncompliance.
3.5 Exceptional violations (Questions 41-45)
Training, rather than procedures, will help reduce the occurrence of these rare, yet dangerous, violations. Flight crews need to know how close they are to the safety limits of their aircraft and how to react in adverse conditions.
It is important to train crews to “think before you act.” Employees need the skills required to deal with rare problems and to foresee the possible dangers associated with their actions.
Exceptional noncompliance often occurs when an employee attempts to solve a difficult and unusual problem for which there is no procedure. In the course of solving the problem, the crewmember may violate a safety procedure. This kind of noncompliance is more frequent in jobs that require a great deal of novel problem solving (e.g., maintenance activities).
An inappropriate reaction is to attempt to write procedures to cover each novel situation as it arises. This is unlikely to succeed as it will only serve to make the employee less able to solve problems and deal with novel situations. Furthermore, it is virtually impossible to envisage a procedures manual that contains sufficient procedures to cover all possible hazards or hazardous situations.
4 Auditing Checks and Actions for Procedures
Procedures are written to increase the predictability of employee behavior. They are a means by which organizations can attempt to control behavior.
Auditing checks and actions for procedures:
- Ensure that existing procedures are correct, available and understood.
- Check the training methods for procedure awareness and use.
- Eliminate unnecessary procedures.
- Review the applicability of procedures.
- Make compliance with procedures rewarding.
- Encourage employees to use their initiative without taking risks.
- Check the way in which procedures are published and distributed.
- Encourage compliance with procedures and the reporting of noncompliance.
5 Supporting Management Actions
- All procedures must be SMART (i.e., specific, measurable, achievable, relevant and timely).
- Ensure that procedures are not “kept on the shelf” and referred to only when a problem arises.
- If an employee needs to know procedures in detail, personal copies are essential.
- Have a consistent and fair enforcement policy implemented by local supervisors.
- Management must continually monitor the ability of employees to follow procedures.
- Consider alternatives to procedures, such as automation or error checking (duplicate processes or inspections).
6 Key Points
- A good procedure has the following characteristics:
- A clear and acceptable aim.
- A scope that matches its purpose.
- A precise statement, leaving no room for doubt about its application in any possible case (i.e., no loopholes).
- A high probability of achieving its purpose without undesirable side effects.
- There are five types of violations (unintentional, routine, situational, optimizing and exceptional), and procedures can be used to address each type of violation.
- The PAT can be used to help an organization or manager understand why employees are not complying with procedures and rules.
- Auditing checks and actions can be used to make sure that procedures are operating as planned and that employees will comply with the procedures.
- All procedures must be SMART: specific, measurable, achievable, relevant and timely.
7 Associated OGHFA Material
8 Additional Reading Material
- Hudson, P.T.W.; Verscuur, W.L.G.; Lawton, R.; Parker, D.; Reason, J.T. Bending the Rules II: ‘Why Do People Break Rules or Fail to Follow Procedures? And What Can You Do About It? The Violation Manual.
- Karwal, Arun K.; Verkaik, Renate; Jansen, Claartje. Non-Adherence to Procedures — Why Does it Happen?
- Hudson, Patrick. “Non-Adherence to Procedures: Distinguishing Errors and Violations.” Airbus 11th Human Factors Symposium. Melbourne, Australia. July 2000.
- New Zealand Civil Aviation Authority. “Airmanship and Maintenance Rule Breaking.” Vector 01-1.
- Embry, David. Preventing Human Error: Developing a Consensus-Led Safety Culture Based on Best Practice. Human Reliability Associates.
- Degani, Asaf; Wiener, Earl L. On the Design of Flight-Deck Procedures.
- NASA/FAA Operating Documents Project. Developing Operating Documents, A Manual of Guidelines.
- IATA Human Factors Working Group. Adherence to Standard Operating Procedures: An Effective Strategy in Accident Prevention.