Standard Operating Standard Operating
ProceduresProcedures
Standard Operating Standard Operating
ProceduresProcedures
Why do pilots not (always)
follow procedures?
Why do pilots not (always)
follow procedures?
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 2Page 2
Procedures and SOPs
To ensure effective compliance with published procedures and
SOPs, it is important to understand why pilots intentionally or
inadvertently deviate
In most cases of deviation, the procedure that was followed in
place of the correct one seemed to be appropriate, considering
the information available
constitute constitute thethe reference referencefor crew standardization and provide the working for crew standardization and provide the working environment required for enhanced and efficient environment required for enhanced and efficient
crew communication and coordination.crew communication and coordination.
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 3Page 3
Purposes of Procedures and SOPs
Establish a common action project
Reduce ambiguities and error risks
Guarantee better task sharing
Reduce crew workload
Facilitate mastering actions and errors
Contribute to situational awareness
Reduce risks of conflicts
• ICAO Air Nav Services on A/C OperationsICAO Air Nav Services on A/C Operations
• FAA AC 120-71 + JAR-OPS 1.104 FAA AC 120-71 + JAR-OPS 1.104
• IATA HFWG on “Adherence to SOP” IATA HFWG on “Adherence to SOP”
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 4Page 4
Outline and Objective of the Presentation
In earlier times:
Incidents and accidents were linked with catastrophic structural, engine or
system failures or with bad weather
Technical evolutions led to a decline of catastrophic failures
At present:
Primary and contributory causes are mostly crew-related (two out of three)
Non-adherence to procedures and SOPs as a threat:
Sources on human error abound: ICAO ADREP, FSF ALAR
Line operations safety audits (LOSA) and reporting confirm the rise of
procedural errors
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 5Page 5
Nonadherence to Procedures Is it really such an issue?
Factors in aircraft accidents 1970-1997
5%
11%
12%
15%
35%
42%
69%
ATC
Maintenance
Aerodrome
Power plant
Environment
Aircraft
Crew
ICAO ADREPICAO ADREP
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 6Page 6
Line Operations Safety Audit (LOSA) Error Frequencies
6
5
6
29
54
0 20 40 60 80 100
Decision
Proficiency
Communication
Procedural
Noncompliance
Percent Frequency
UTX UTX But what about But what about consequences?consequences?
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 7Page 7
The Rise of Procedural Noncompliance
Procedures are being increasingly written to shape crew behavior toward
what is considered to be safe
“Hard” design combined design combined with “soft” procedural defenses procedural defenses encourage
deviations
The overabundance of SOPs mostly stems from:
– the need to adapt to constantly changing habits and policies
– the need to increase capacity and efficiency of operations
– the need to manage an increasingly complex environment
Understanding noncompliance can be done from a variety of angles:
Cognitive, Behavioral, Ergonomic,
Safety Management and Data Analysis
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 8Page 8
23 Types of Procedural Nonadherences
No perception of relevant information (input)
Misperception of information (pattern matching)
Procedural design (input, interpretation)
Procedural experience/training (long-term memory)
Cultural aspects (influencing factors)
Personality aspects/attitudes (influencing factors)
Situational factors (influencing factors)
Decision-making heuristics (decision making)
CRM (awareness and attention management)
Further reduced to nine subcategories for remedial action:Further reduced to nine subcategories for remedial action:
TRAININGTRAINING OPERATIONSOPERATIONSDESIGNDESIGN
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 9Page 9
The Behavioral Approach: Errors and Violations
MMOOTTIIVVAATTIIOONN
POWERFULNESSPOWERFULNESS
ATTITUDESATTITUDES
SOCIAL SOCIAL NORMSNORMS BEHAVIORBEHAVIOR
INTENTIONINTENTION
EXPECTATIONEXPECTATION
PLANNINGPLANNING
CONSEQUENCECONSEQUENCE
OPPORTUNITIESOPPORTUNITIES
EXTERNAL EXTERNAL GOALSGOALS
Verschuur and Hudson
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 10Page 10
Eight Types of Procedural Nonadherence
Four types of violations based on performance levels:Four types of violations based on performance levels:
– routine violations: common practice becoming group norm
– optimizing violations: challenge when rules are too restrictive
– situational violations: dictated by immediate environment
– exceptional violations: unusual or unfamiliar circumstances
Four types of errors based on operational taxonomy:Four types of errors based on operational taxonomy:
– procedural errors: correct intention/incorrect execution
– communication errors: incorrect transmission/interpretation
– proficiency errors: insufficient knowledge and/or skill
– operational decision errors: unnecessary increase in risk
Intentional “violations” and “unintentional noncompliance” (errors) Intentional “violations” and “unintentional noncompliance” (errors)
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 11Page 11
EVENT RECOGNITION PROCEDURE REMARKS
WARNING EXECUTION
LOSS OF IRS DATA "ATT" FLAG IS NOT SOPs FOR NOT MOVING "ATT" WARNING WILL
AFTER TAKEOFF DISPLAYED ON PFD, WITH THE AIRCRAFT DURING IRS BE DISPLAYED ASA 300 - 600 HONEYWELL IRU, IF A/C IS MOVED ALIGNMENT SOON AS EXCESSIVE
JUST AFTER PFD DISPLAY MOTION DETECTEDCOMES ON
RETURN TO GATE FQI LESS THAN REQUIRED ON PREVIOUS LEG, ARRIVAL FOB ALT TO THR CLB / NOT CHECKED VERSUS DEPARTURE
OPEN CLB WITH FOB LESS TRIP FUEL PER SOP AIRCRAFT DESCENDING
AT IDLEA 320
BRUTAL DOOR ECAM DISPLAY RESOLUTION? SOP STATE "CHECK DIFFERENTIALOPENING AT GATE PRESSURE IS ZERO…"
A 300 - 600
EVENT RECOGNITION PROCEDURE REMARKSCREW DIAGNOSIS EXECUTION
NAVIGATION NO F-PLN ABNORMALITY NO FOR F-PLN CROSSEDDEVIATION AFTER NOTED DURING COCKPIT CHECK ?
GO AROUND PREPARATION
NAV DEVIATION DETECTED BY ATC FOR NAV MONITORINGDURING SID ?
NAV LINE ANOMALY OBSERVED ON PFD
RADAR VECTORS ISSUED TO
RECOVER F-PLN AT "TO WPT"
Absence of Recognition Leading to Nonadherence to Procedures
What is absence of r
ecognition other t
han a trap in
to lack of r
igor?
What is absence of r
ecognition other t
han a trap in
to lack of r
igor?
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 12Page 12
Recognition Issue Leading to Nonadherence EVENT RECOGNITION RECOGNITION PROCEDURE REMARKS
WARNING CREW DIAGNOSIS EXECUTION
ENG TAIL PIPE FIRE NO ENG FIRE WARNING ENG TAIL PIPE FIRE ENG FIRE DRILL APPLIED
A 310 TRIGGERED REPORTED BY ATC ENG TAIL PIPE FIRE NOT APPLIED
ENG FLAMEOUT DUE UNDETECTED FUEL OUTR TANK QRH PROCEDURE NOT FUEL FEED
TO FUEL STARVATION AUTOFEED FAULT LOW LEVEL FOLLOWED FROM OUTR TANKA 300 - 600 DISREGARDED AS SUSPECTED FOLLOWING FAULT
SPURIOUS
THROTTLE LEVER THROTTLE LEVER NOT AT IDLE AIRCRAFT PUSHED TRACTOR NON COMPLIANCE WITH 6 EVENTS SO FAR
NOT AT IDLE NOT SET AT IDLE ABOUT 10 FEET BACK SOPs FOR SETTING THRDURING MES MESSAGE CREATED LVR TO IDLE BEFORE MES
A 320
UNWARRANTED IFSD DECREASING OIL PRESSURE MISUNDERSTANDING UNWARRANTED ENGINE TYPICAL CASE OF
BASED ON DECREASING BUT NO LOW OIL PRESSURE OF OIL PRESSURE AND LOP SHUTDOWN HURRIED REACTIONOIL PRESSURE WARNING INDICATIONS CLIMB PHASE
A 320How can recognitio
n issue le
ad to procedural a
dherence?
How can recognitio
n issue le
ad to procedural a
dherence?
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 13Page 13
Procedural Subtlety Leading to Nonadherence
EVENT RECOGNITION PROCEDURE PROCEDURE CREW ACTION REMARKS
CREW DIAGNOSIS CONTENTS EXECUTION
VIOLENT OPENING FAILURE TO RECOGNIZE "ON GROUND EMER / EVAC" PROC FAILURE TO COMPLETE DOOR OPENING WITHOUT CAB PRESS
ON GROUND THAT A/C WAS STILL DOES NOT POINT THAT RAM AIR "CAB PRESS MAN CTL" POSITIVE CONFIRMATION DIFFICULTIES +A 300 - 600 PRESSURIZED EFFECT IS WITH CAB PRESS PROC BEFORE CALLING EVACUATION OF DEPRESSURIZATION LAV / CARGO
IN AUTO ONLY AND DOING THE CRM AND WORKLOAD ISSUE SMOKE WARNINGS"ON GROUND EMER / EVAC" PROC
EVENT PROCEDURE CREW REMARKSEXECUTION ACTION
ENG FAILED TO FOT AND FCOMREACH TAKE OFF ENG NOT SHUTDOWN ENG SET AT IDLE ONLY REVISION
POWER DUE TO PLANNEDFUEL LEAK
A 320
EVENT RECOGNITION CREW REMARKS
WARNING ACTION
RTO DUE TO ECAM WARNING TRIGGERED BY
ENGINE PREVIOUS CREW AWARENESSTHRUST LOSS MESSAGE A.ICE ENG LATE RTO ACTION NEED TO AVOID SUCH
A330 VALVE OPEN SITUATIONS IN ANYECAM AT 80 KT / FUTURE DESIGN
A. ICE ENG 1 VALVE OPEN CREW RTO AT 130 KTAWARENESS MESSAGE
ACTIVATED AT HOLDING POINT
AWARENESS MESSAGE AND ECAM WARNING
NOTE TO BE ADDED IN FCOM
TO ANTICIPATEINTERLINK BETWEEN CREW
PROCEDURE
CONTENTS
RECOGNITIONCREW DIAGNOSIS
LOW POWERHIGH FUEL LOW
VISIBLE FUEL LEAKFROM ENGINE
How can procedural subtlety lead to correct adherence?
How can procedural subtlety lead to corre
ct adherence?
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 14Page 14
Rushed Action Leading to Nonadherence EVENT RECOGNITION PROCEDURE CREW REMARKS
CREW DIAGNOSIS EXECUTION ACTION
ALT DEV IN TURBULENCE TURBULENCE READINESS IF TURB WAS FORECAST SP/ALT HLD CREW DISCONNECTED AUTOPILOT
WITH PROFILE MODE FROM FORECAST SHOULD HAVE BEEN PREFERRED TO RATHER THAN LEAVING PROFILEA 300 - 600 PROFILE MODE (REVERSION TO SPD/ALT HLD)
AP + A/THR + PITCH TRIM NONE SOPs NOT COMPLIED WITH AP DISCONNECTION BY STICKDISCONNECTION + FOR PREVENTION AND RECOVERY FORCE SUSPECTED
ALT DEV IN TURBULENCE MANUEL RECOVERY AND A 310 AUTOPILOT REENGAGEMENT
TURB ENCOUNTER POSITIVE QRH NOT APPLIED FOR OVERSPEED SPEED BRAKES EXTENSION TRAINING ISSUE ?AND STALL PREVENTION AND RECOVERY AS SPEED UP TO MMO
A 310 CREW RESISTED THE AUTOPILOT A-THR REDUCING TRUSTAT FL 350
SPEED DECREASING TO STALL WARNING
OUT OF TRIM
CONDITION CORRECTED BY F/O PNF
AP REENGAGED
RECOVERY AT FL330
COLLISION WITH BREAK PRESSURE CREW FAILURE TO CONFIRM PARKING
JETWAY ON ARRIVAL NOT VERIFIED BRAKE PRESSURE BEFOREA 320 RELEASING PEDALS AND SHUTTING RELEASING PEDALS AND SHUTTING
ENGINES DOWN, PER SOP ENGINES DOWN PEMATURILY
What is ru
shed action other th
an premature decision making?
What is ru
shed action other th
an premature decision making?
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 15Page 15
Undue Interpretation Leading to Nonadherence
EVENT RECOGNITION PROCEDURE CREW REMARKS
CREW DIAGNOSIS EXECUTION ACTION
ENGINE FIRE BECAUSE PARAMETERS WAS ECAM DISREGARDED SPURIOUS WARNING SPURIOUS WARNINGWARNING AND IFSD NORMAL, EXCEPT OQ "XX" SHOULD BE CORRECTED SHOULD BE CORRECTED
PERFORMED 54 CREW CONCLUDED TO SPURIOUS EFFECTIVELY AND EFFECTIVELY AND MINUTES LATER WARNING DESPITE 2 VISUAL QUICKLY TO PREVENT QUICKLY TO PREVENT
A 330 INSPECTIONS CREW DISREGARDING CREW DISREGARDINGWARNING ACTIVATION WARNING ACTIVATION
IFSD WHEN OP "XX" AFTER 54 MINUTES
EVENT RECOGNITION PROCEDURE CREW REMARKS
WARNING EXECUTION ACTION
IFSD BASED ON STEP DECREASE OF ENGINE DECREASING OIL QTY OR OIL QTY PRECAUTIONARY IFSD NO OIL LEAK
DECREASING 1 OIL QTY ADVISORY CALL ONLY FOR + FOUND BUT …OIL QTY MONITORING OF OIL PRESS DIVERSION 14 QTS ADDED !
A 321 AND OIL TEMP
What is undue in
terpretation other th
an biased decision making?
What is undue in
terpretation other th
an biased decision making?
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 16Page 16
From Recognition and Execution to ...
EVALUATIONEVALUATION of Constraints of Constraints
INTERPRETATION INTERPRETATION of Consequencesof Consequences
IDENTIFICATION IDENTIFICATION of the State of a Systemof the State of a System
SEARCH SEARCH for Informationfor Information
DETECTION DETECTION of Abnormal Conditionsof Abnormal Conditions
Adapted from Rasmussen (1986)
DEFINITION DEFINITION of a Taskof a Task
FORMULATION FORMULATION of a Procedureof a Procedure
EXECUTION EXECUTION of Actionsof ActionsSkillsSkills
RulesRules
RulesRules
Knowledge
Knowledge
KnowledgeKnowledge
Knowledge
Knowledge
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 17Page 17
From Machine Minding to Decision Making
From a two-stage to a three-stage processFrom a two-stage to a three-stage process
Wave of RecognitionWave of Recognition • Perception of WarningsPerception of Warnings
• Interpretation by CrewInterpretation by Crew
Wave of ExecutionWave of Execution• Procedure SpecificationProcedure Specification
• Procedure ExecutionProcedure Execution
Wave of Decision MakingWave of Decision Making
• Evaluation of OptionsEvaluation of Options
• Expectation of How to DoExpectation of How to Do
• Formulating the Intention Formulating the Intention
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 18Page 18
Causal Factors in Approach and Landing Accidents Inadequate decision making 74%Inadequate decision making 74%
Omission of action or inappropriate action 72%
Nonadherence to criteria for stabilized approach 66%
Inadequate CRM practice
(coordination, cross-check, backup) 63%
Insufficient horizontal or vertical
situational awareness 52%
Inadequate or insufficient understanding
of prevailing conditions 48%
Slow or delayed action 45%
Flight handling difficulties 45%
Deliberate non-adherence to procedures 40%
Incorrect or incomplete pilot/controller communication 33%
Interaction with automation 20%
No go-around when required 17%
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 19Page 19
Pilots use recognitive processes in the deployment
of procedures, which may be accompanied by errors
– Effective crews apply judgment to direct decision makingEffective crews apply judgment to direct decision making
Pilots’ natural risk-evaluation strategies help them to distinguish
consequential errors from benign ones
– This hinges on knowing how to trade off a variety of human factorsThis hinges on knowing how to trade off a variety of human factors
Applying procedures can be repetitive, rather than sequential, even
under heavy time pressure
– Effective crews avoid rushed overreactions, if at all possibleEffective crews avoid rushed overreactions, if at all possible
ConclusionsConclusions
Non Adherence to ProceduresNon Adherence to Procedures 1.PQ_03_Vis_Issue11.PQ_03_Vis_Issue1Page 20Page 20
ConclusionsConclusions (continued)
The challenge of the future is to develop decision aids,
cockpit and training systems that support rather than hinder the way
good decision makers make decisions
– Experienced crews tap a vast reservoir of alternatives
These procedures and SOPs should enable pilots to
exercise discernment and good decision making
– They should be simple and accurate and with easy-to-assess
consequences
There is an enlarged role for pilots to be trained in
decision making while using relevant procedures
SimplicityAccuracy
Top Related