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

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.


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”


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


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


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?


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


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


The Behavioral Approach: Errors and Violations

MMOOTTIIVVAATTIIOONN

POWERFULNESSPOWERFULNESS

ATTITUDESATTITUDES

SOCIAL SOCIAL NORMSNORMS BEHAVIORBEHAVIOR

INTENTIONINTENTION

EXPECTATIONEXPECTATION

PLANNINGPLANNING

CONSEQUENCECONSEQUENCE

OPPORTUNITIESOPPORTUNITIES

EXTERNAL EXTERNAL GOALSGOALS

Verschuur and Hudson


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)


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?


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?


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?


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?


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?


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


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


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%


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


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

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