1. Standard Operating Procedures Why do pilots not (always) follow procedures?

2. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 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 the reference for crew standardization and provide the working environment required for enhanced and efficient crew communication and coordination.

3. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 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 Operations ICAO 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”

4. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 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

5. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 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 ADREP

6. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 6 Line Operations Safety Audit (LOSA) Error Frequencies UTX But what about consequences?

7. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 7 The Rise of Procedural Noncompliance Procedures are being increasingly written to shape crew behavior toward what is considered to be safe design combined procedural defenses “Hard” design combined with “soft” 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

8. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 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: TRAININGOPERATIONS DESIGN

9. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 9 The Behavioral Approach: Errors and Violations MOTIVATIONMOTIVATIONMOTIVATIONMOTIVATION POWERFULNESS ATTITUDES SOCIAL NORMS BEHAVIOR INTENTION EXPECTATION PLANNING CONSEQUENCE OPPORTUNITIES EXTERNAL GOALS Verschuur and Hudson

10. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 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)

11. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 11 Absence of Recognition Leading to Nonadherence to Procedures What is absence of recognition other than a trap into lack of rigor?

12. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 12 Recognition Issue Leading to Nonadherence How can recognition issue lead to procedural adherence?

13. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 13 Procedural Subtlety Leading to Nonadherence How can procedural subtlety lead to correct adherence?

14. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 14 Rushed Action Leading to Nonadherence What is rushed action other than premature decision making?

15. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 15 Undue Interpretation Leading to Nonadherence What is undue interpretation other than biased decision making?

16. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 16 From Recognition and Execution to... EVALUATION of Constraints INTERPRETATION of Consequences IDENTIFICATION of the State of a System SEARCH for Information DETECTION of Abnormal Conditions Adapted from Rasmussen (1986) DEFINITION of a Task FORMULATION of a Procedure EXECUTION of Actions Skills Rules Rules Rules Knowledge Knowledge Knowledge

17. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 17 From Machine Minding to Decision Making From a two-stage to a three-stage process Wave of Recognition Perception of Warnings Interpretation by Crew Interpretation by Crew Wave of Execution Procedure Specification Procedure Execution Procedure Execution Wave of Decision Making Wave of Decision Making Evaluation of Options Expectation of How to Do Expectation of How to Do Formulating the Intention Formulating the Intention

18. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 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%

19. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 19 Pilots use recognitive processes in the deployment of procedures, which may be accompanied by errors – Effective 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 factors Applying procedures can be repetitive, rather than sequential, even under heavy time pressure – Effective crews avoid rushed overreactions, if at all possible Conclusions

20. Non Adherence to Procedures 1.PQ_03_Vis_Issue1 Page 20 Conclusions Conclusions (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 Simplicity Accuracy