Revisiting the Failure to Follow Procedures Challenge

Johnson revisits the issues associated with failure to follow procedures (FFP). What’s new? Not a lot! It’s the same people doing the same maintenance tasks, on the same familiar aircraft, with the same OEM procedures or company job cards, committing the familiar FFP sins. Here's an update.

Key Players

OEMs strive to develop useable and understandable instructions for those who maintain their products. It is in their best commercial and safety interest to get the technical instructions right. They have systems in place for users to make suggestions on document improvement, as necessary. The same is true for operators, who convert OEM instructions into company-specific job cards. There is no reason that they would purposely make the instructions difficult to use. This author does not believe that the complexity or inaccuracy of technical instructions is the primary cause of FFP. Of course, it is a very good and often used excuse from users.

Mechanics and those that maintain aircraft continuously strive for quality and safety. The same is true for those who manage maintenance activity. All parties benefit from doing every task properly with no requirement for rework; no compromise in operational safety; or for any regulatory noncompliance. While intentions are honorable, too often the “Heat of Battle” to meet time and production pressures overrides ideal application of written procedures.

Regulators and corporate lawyers are often blamed for the complexity and redundancy in written procedures. There is no reason that regulators or lawyers would purposely make instructions difficult to use. Perhaps there is a well-intentioned culture to be thorough and safe vs. being simple and maybe risky. In any case there are certainly many examples of the complexity of potentially simple instructions because of cautions from overzealous regulators and lawyers.

Whether it’s the OEM, the document users, the regulators, or the lawyers there are many opportunities for improvement. FFP is among the largest safety issues in aviation maintenance, actually in every aspect of aviation. It leads to errors from the landing checklist of Piper Cub to the diagnostic procedures of a B 787.

Asking Questions

When trying to address the FFP challenge some say the solution is based on “who you ask.” So FAA researchers asked various industry segments about following procedures. Applied Ergonomics Group (AEG), led by Dr. Colin Drury, conducted the work under an FAA contract. Drury has been working on the human factors of technical instructions since the format went from hieroglyphics on stone to parchment paper to I-pads (actually for only about 50 years). Using hundreds of event reports from the National Transportation Safety Board, the FAA-NASA Aviation Safety Reporting System, FAA technical reports, and the extensive AEG experience, they created a classification scheme, a listing of best practices, and a structured interview form for maintenance personnel and management. They went to eight diverse organizations that write and use written technical instructions. At each location AEG conducted extended private one-on-one interviews, totaling over 150 personnel (all extensively documented in the FAA report to be published in 2018). These interviews focused on FFP incidents and on best practices to ensure that procedures are followed. They helped ensure that our team fully understood the challenges to generate excellent samples of best practices.

Categorizing Areas of Opportunity for Action

In order to address FFP the broad term must be broken into categories. There have been many classification breakdowns to categorize challenges and solutions. Readers are likely familiar with PEAR that addresses People, Environment (Physical and Social-Cultural Environment), Actions performed, and Resources necessary to complete the job. For this project AEG created the term TAPES.

TAPES stands for five critical areas that affect the FFP challenge. T represents the kind of FFP errors that are made during a given maintenance task. A stands for actor, everything about the person who is using the procedure. P stands for the procedure itself. E refers to the physical environment in which the procedures are used. Finally, S refers to social meaning all of the operational and cultural characteristics of the work location and/or the total organization. AEG focused TAPES not only on the maintenance personnel using the procedure but also procedure developers.

Best Practices

Here are example best practices categorized using TAPES

T – Task

• Perform all tasks in the specified order

• When a procedure is problematic correct it at the working level

• Formally recover from any distractions or interruptions in the task

• Be sure to sign off each subtask

A – Actor

• Ensure training and qualification for the task

• Be committed to following the procedures

P – Procedure

• Have a clear procedure that identifies task completion

• Immediately communicate irregularities in the procedure

• Know that “tribal knowledge” is not necessary in a procedure

E – Environment

• Recognize present risk from issues like lighting, temperature extremes

• Address adverse environmental conditions as possible

S – Social

• Everyone must address time pressure, always

• Stop and ask if unclear on task or procedure

• Rely on and apply positive safety culture among peer group

Next FAA Actions on FFP

The work related to FFP is endless. That is due to the nature of the aviation maintenance environment and culture. First, FAA will get all the reports published. The writers and editors are keenly aware of at least two separate and different audiences for this FFP research. One audience is the research community, who wants to see the data collection, how it was analyzed, and how it can be transferred to other R&D and to applied solutions. The FAA technical reports will satisfy that audience.

The most important audience is the users/writers of technical procedures. FAA is aware that mechanics know the regulations and the importance of using the written technical procedures. However, knowledge is not enough! The practical products from the research project must alter daily attitude and behavior about explicit use of the procedures. That change must permeate the culture of maintenance from the top executive to the new hire. FFP is not a technical issue. It is a culture issue about attitude and commitment. Our next deliverable will be part two. At press time of this article we are building a training system that focuses on the culture of procedure following. We will supplement the web-based training system with job cards and workplace signage that will serve as a constant reminder to all. We proceed to this next step with full knowledge that changing the culture of FPP will not be easy. However, we are certain that the next important step in our continuing safety efforts centers on following the procedures. Stay tuned in 2018!

The author acknowledges all who contributed to this large project including but not limited to the FAA Civil Aeromedical Institute Human Factors Division, the Cherokee CRC, the Applied Ergonomics Group, the 160 mechanics and supervisors, and their eight companies.