Rogue Pilots or Just Bad Procedures?

Procedural noncompliance is a topic that gets a lot of attention. In most recent studies, much of the focus centers on pilots who intentionally deviate from a procedure because they are either too complacent, unprofessional, or worse, just bad apples.

The “fast thinker”—those seeking cognitive ease—might buy into this notion. For them, blaming an incident or accident on a “rogue” pilot is easy. Pilots should just follow the procedures and incidents and accidents won’t occur. Their solution: remove that individual, issue a bulletin for the rest to “comply,” and the problem will go away, right?

The “slow thinker”—those wrestling with cognitive strain—will question the notion of a “rogue” pilot, understanding that complex issues don’t have one single solution, nor will they simply go away. The solution in this case might begin with identifying the human-factors issues associated with noncompliance and a healthy reflection on the procedures themselves. Line operations safety assessments (LOSA) studies suggest a high prevalence of noncompliance often points to an ineffective or bad procedure.

At one time, procedural noncompliance was on the NTSB’s “Most Wanted List” and currently is a top safety issue for the NBAA Safety Committee. NBAA identifies procedural noncompliance as a significant contributing factor in aircraft accidents and incidents. Furthermore, NBAA recommends, “Aviation professionals in all vocational categories must become aware of the extent that noncompliance has proliferated in business aviation, identify the causal factors for noncompliance and develop workable solutions that eliminate these events.”

Universally, it’s recognized that good procedures ensure standard pilot actions. Likewise, pilots adhering to good procedures enhance aviation safety. Thus, there’s typically a bad outcome when pilots intentionally don’t follow procedures. In fact, it’s a very slippery downward slope.

The LOSA Collaborative, founded by Dr. James Klinect, has more than 20,000 observations in its archive. This data shows that, on average, “Flights that have two or more intentional noncompliance errors have two to three times as many mismanaged threats, errors, and undesired aircraft states as compared to flights with zero intentional noncompliance errors.”

Intentional noncompliance by pilots might be more closely related to science than bad behavior. Some human-factors studies suggest that there are a number of issues related to a pilot becoming intentionally noncompliant. Often, these pilots, given a poorly written procedure, simply do not agree with the procedure and might believe their way is better—“an informed workaround.” Others might not fully understand a procedure or the risk associated with not complying. Additional factors such as fatigue can also play a role in intentional noncompliance.

Researchers also point toward three “perceived justifications” of being noncompliant: rewarding the violator (for example, “I get home earlier if I don’t go-around”); knowledge of associated risk (for example, “My risks are justified because I know better…”); or consideration of peer reaction (for example, “My reputation precedes me. I am a good pilot.”). The trick is to break these perceptions.

Organizations also have some culpability when it comes to procedural noncompliance. Operators must understand that there are indeed bad procedures. When it comes to developing and writing good procedures, words and actions matter.

Advisory Circular 120-71B provides some outstanding guidance on the design, development, and implementation of SOPs and checklists. It goes into great detail about the importance of providing flight crews background information on a new procedure or a change in existing procedure. Background helps a crew “buy into” the procedure by providing context and relevance.

According to the AC, implementation of any procedure is most effective when the procedure is appropriate for the situation; the procedure is practical to use; crewmembers understand the reasons for the procedure; pilot flying and pilot monitoring duties are clearly defined; effective training is conducted; adherence to standard is emphasized; and crewmembers understand the risk and hazards of not following the procedures.

For any developer or manual writer, this AC is a must. As an example, the use of ambiguous words—such as should or may—often leads a crew to noncompliance, by simply giving them an option not to comply. The AC recommends the use of more positive words—such as do and must—since they are easier to read and less likely to be misunderstood.

Procedural noncompliance is a difficult issue to identify within an organization. LOSAs, when compared to the other voluntary safety programs, are one of the most effective tools to identify procedural noncompliance by highlighting areas where it is most prevalent. From those results, an organization can determine if it’s a pilot problem or organizational problem

Pilot, safety expert, consultant, and aviation journalist Stuart “Kipp” Lau writes about flight safety and airmanship for AIN. He can be reached via email.


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