Aftermarket: Why Good Employees Violate Procedures — Is it Inevitable

The dynamics of procedural non-compliance are complex. This is the first part in a two part series aimed at understanding how and why employees violate compliance and keys to controlling this phenomenon. Part II in next month’s issue will discuss the situationally dependent nature of compliance, how work-adaptive behavior can be harnessed to create operating efficiencies, and recommendations to create more compliance.

You’re on the way to the office, looking forward to that first cup of coffee, when the VP of engineering calls your mobile phone to advise you that someone in your department has damaged a very expensive aircraft component during maintenance — he expects answers and action. You quickly determine that one of the department’s better certificated maintenance technicians assembled the component without following procedures and that his actions caused the damage. "We can’t have that kind of thing going on in this department," you think. You call the technician to your office and tell him, "You’re fired!"

You think his termination will send a strong message to ensure the other technicians follow the procedures from now on and that you solved the problem quickly and quite well. Did you really?

It would be welcome news to advise you that there existed a magic bullet solution to reduce the number of times aviation employees behaved in procedural non-compliant ways. Regrettably, there are many logical reasons why that simple solution does not exist. The good news is that there are a number of inexpensive and effective strategies that knowledgeable managers can use to make procedural compliance more likely. Managers need a concise guide outlining the dynamics of procedural non-compliance which will be discussed in this issue. In next month’s Aviation Maintenance, we will discuss the situationally dependent nature of intentional non-compliance, how work-adaptive behavior can be harnessed to create operating efficiencies and loss reduction, and some recommendations that managers may implement to create more beneficial conditions for compliance as well as more effective procedures.

Procedural Non-Compliance

A reason that this topic is a background issue may be that hard data estimating the total losses to the aviation industry through employee non-compliance does not exist. However, by inference, we can begin to understand the magnitude of the problem by considering the Boeing Commercial Airplane Group’s analysis of commercial jet airplane hull loss statistics from 1982–1991. Boeing claimed that flight crew adherence to procedures could have prevented more than 50 percent of the 232 fatal hull losses. 1

To further attempt to quantify the scope of industry losses, we should keep in mind that the Boeing data constituted only fatal aircraft accidents. If we include losses for the damages and injuries that occurred that were not defined as fatal, the ground support incidents, the equipment damage, and the lost revenue caused by procedural non-compliance by employees from all air transportation operational disciplines, the loss amounts could be staggering. There is no evidence to support a conclusion that current loss values are significantly different than in the 1990s; if anything, one might expect them to be higher given the increase in air transportation statistics.

Aside from the obvious reasons why procedural non-compliance is an issue worthy of management consideration, there is an economic element that we may overlook. Those familiar with any of the several industrial accident triangle ratio models would be aware that for every major injury accident there are 50 or fewer minor injury accidents, and between 400 to 600 near miss events. (Near miss, as used within the context of safety parlance, is an event that "nearly" caused an accident or incident but for some factor(s) the event did not occur.)

It is easy to focus on the tip of the triangle, below, and overlook the far wider base of minor events. However, we need to keep in mind the individual events comprising the triangle have a common element: loss or diversion of resources. Whether people are involved in recovery efforts resulting from a major accident or investigating and implementing corrective actions from near miss events, organizational attention shifts from production activities to other housekeeping functions. I contend that within an accident triangle model of the air transportation industry there exists an ocean of lost resources. The probability of a major accident is low; continuing and frequent losses through intentional and unintentional non-compliance are certain — the only question is how much.

A 2005 Internet survey of operational aviation professionals provided an interesting and troubling aspect of the loss equation. That survey indicated 63 percent of those professionals estimated intentional non-compliance events were occurring on a frequent to occasional basis. There were three primary respondent groups in the survey: flight crewmembers, maintenance personnel, and managers. What may be of particular interest to maintenance managers is that of the three groups, maintenance technicians were the least likely to attribute non-compliance as a factor in accidents, incidents and near miss events and managers the most likely. 2 Which of the two groups do you estimate is kidding themselves?

Without hard data to support resource allocation decisions, who would bother to fix something that they did not consider broken? Even more problematic, it would appear that managers underestimate the level of non-compliant behavior throughout the air transportation operating system because few non-compliance events actually end in accidents or significant incidents. Managers do not observe directly attributable revenue losses or they accept the losses as routine costs of operation and they do not investigate further. However, unless they understand the conditions that set up the situations for violations, they will not be able to manage the conditions intelligently; employees and managers will continue to make similar judgemental errors when confronted by similar conditions. Albert Einstein defined insanity as doing the same thing and expecting a different result.

Helmreich, using data from Line Operational Safety Audits (LOSA) made the claim that flight crews who commit intentional non-compliances commit 25 percent more errors of other types. 5 Compound that observation along with the predictable assortment of non-compliances from throughout the interactive and interrelated elements of the air transportation system and then recalculate the above equation. The possible totals yield considerable scope for mishaps.

System Dynamics

Every enterprise has essential, common elements designed to: (a) process input resources into products or services, and (b) complete that process profitably. The product, service, and the type of profit or benefit can be anything. To produce any given outcome, one needs to understand that a state of tension exists between the way individuals adapt to complete their tasks and an organization ensuring a high degree of predictability regarding the end product. The use of effective rules and procedures is a means of improving the likelihood of predictability. 6

In addition to the variability factor, human error is an inescapable characteristic of our nature that will always be a factor in any endeavour. System engineers devise ways to factor in its inevitability and design safeguards to either reduce the chances of an error occurring or to contain its dangerous effects if an error should occur.

To better visualize the design safety function, imagine three irregularly defined zones of operation: Inherently Safe, Normal Operations, and The Edge (see Figure 2 page 24). The irregularity of the shapes represents the continuous variability of the conditions in which operations occur. System designers take into account the likely operational conditions employees encounter and build in margins of safety that allow for a degree of equipment and individual variability during normal operations. As long as people operate according to valid design procedures in the Normally Safe Zone, aside from abnormal conditions, they may be reasonably assured of safe operations or the ability to recover from equipment failures and minor errors.

The farther one ventures into The Edge Zone, the greater the likelihood for losses. Note the relationship of PiNC and PuNC events and the zones. Those events can erode the design safety margins and take people into, or beyond, The Edge Zone – an area where design engineers have not made contingencies; an area beyond the safe design envelope: unchartered territory. Intentionally operating beyond the Normally Safe Zone undermines safeguards and it happens for a variety of reasons.

Generally, socialized people do not set out with the intention of purposely jeopardizing their safety or others’ well being. Therefore, there must be a reason why there are so many incidents of intentional non-compliance throughout the industry. The results of the previously mentioned Internet survey indicated that the majority of the respondents estimated that most people violated procedures because they were either trying to get the job done or that procedures were inadequate in some manner or both.

Hard-Wired for Risk and Adaptation

To begin to understand PiNC, we need to understand how humans generally regard risk, how and why they adapt procedures to situational conditions, and how they manage themselves when deciding to undertake potentially risky ventures. To imagine risk and adaptation as bad things would be simplistic and absurd; it is not the risk or the adaptation themselves that are bad, it is the way in which we interact with them and manage them that causes losses.

We need to manage risk and we need to adapt to changing situations in order to survive. We face hazards of many types on a routine basis every day. In fact, we’ve evolved as a species, in large measure, into natural risk optimizers and effective, creative adapters and for the most part we are usually successful in those processes. Our conscience normally warns us when the risks are obviously too great for the benefits we expect.

The process can even work subconsciously; have you ever felt the hair on the back of your neck raising up when you expose yourself to some risks? It’s a natural process. It isn’t the risk or the adaptations that are the problem, it is the context in which they occur. For example, it is appropriate for a race car drive to use excessive speed on a racecourse; however, it is not appropriate for a tug driver to speed on the airport apron.

Given that humans have evolved to become natural risk optimizers as well as efficient maximizers of resources, it is unrealistic to imagine that when people arrive at work they might store these natural and mostly beneficial qualities in their lockers and don the uniforms of robotic organizational conformity. It simply doesn’t happen and it is naive of managers to imagine that it might. To insist that employees stop assessing conditions and developing work-arounds to accommodate changing situations would be to doom organizations to premature obsolescence.

Actually, there are a number of psychological factors hard-wired into humans that can predispose employees to PiNC. The Modified Situation Control Theory 7 indicates that given a reasonable benefit and reasonable chance that no one may detect the violation and the violator would not suffer adversely from their peer group — there is a far greater than even chance the person would violate. The debatable Risk Homeostasis Theory 8 as well as established social psychological thinking indicates that people are natural risk optimizers and generally tend to overestimate their abilities and to underestimate levels of risk.

As an industry, we don’t do enough to help people manage their natural inclinations to take calculated risks and to devise operational efficiencies — especially when they see opportunities for benefit or to make processes easier. Some regulators and managers have unrealistic expectations regarding peoples’ motivations to adhere to procedures. If we expect predictable behavior, then we must design effective procedure management systems that accommodate natural inclinations. Our assessment of risk and our tendency to adapt are but two elements in a cocktail of factors contributing to PiNC.

We need to accommodate human nature just as we manage any other hazardous condition, the better we understand and manage the hazardous elements of our behavior and design control measures to obtain maximum efficiency from its positive elements, the safer and more profitable the industry becomes.

Conclusion

The costs of PiNC are staggering. PiNC facilitates losses, and people are hard-wired to a degree of PiNC behavior.

Managers have a responsibility to provide an organizational environment that aids employees in managing their natural abilities to efficiently adapt to changing conditions. Employees have a responsibility to provide feedback about current operating conditions and adaptive work strategies. System improvement becomes a joint venture partnership of evaluating employee-generated adaptations, legitimizing effective work improvements, and implementing the changes. The organization becomes what may be termed a learning organization.

Ed Mitchell, MSc., MRAeS, is a practicing aviation safety manager and is pursuing a PhD in air transport engineering with City University London. He is researching ways to reduce the number and complexity of published procedures while maintaining equivalent or higher levels of safety. Mr. Mitchell’s MSc thesis, which studied procedural non-compliance among air transportation employees, collected data regarding intentional non-compliance and presented strategies to reduce violation events, forms the basis of this two-part article.

Why Procedural Non-Compliance is Costly and Hazardous

Essentially, PiNC increases the likelihood of losses and accidents. The following considerations present a good selection of factors that could make procedural non-compliance a losing proposition:

• PiNC takes people outside the boundaries of safe working practice, making the environment less forgiving of errors. In other words, PiNC circumvents one layer of defence, the procedures, which aim to ensure predictable and safe working practice.

• PiNC decisions can themselves be errors when the individual does not know or understand the procedure. This lack of understanding is dangerous in itself, because while not appreciating the risk, people often fail to protect themselves.

• PiNC can take people to new or unpractised situations, in which the person is more likely to make an error.

• PiNC breaches the last line of defence. Procedures are barriers put in place because we have run out of all other possibilities such as, design, hardware and avoidance of the problem. 4 Built upon the reasons for not violating is another element highlighted in the literature, the violator almost always assumes that everyone else will do the right thing. They don’t imagine that their planned procedural non-compliance could meet other peoples’ PuNC, unexpected system malfunctions, and that the unexpected combinations can escalate the possibility of losses in unimaginable ways. Hudson et al developed a Violation Equation4, in which I have slightly modified the sum: Violation + Error = Losses

References

1. Graeber, R., Moodi, M. (1998). Understanding Flight Crew Adherence to Procedures: The Procedural Event Analysis Tool (PEAT). Retrieved 2005, http://www.boeing.com/commercial/flighttechservices/peat03.pdf.

2. Mitchell, E. (2005). Strategies to Reduce Aviation Employees’ Procedural Non-Compliance. MSc Thesis, City University London. http://aviationsafetyadvisors.com/edthesis.pdf

3. Huntzinger, D. (2005). Procedural Non-Compliance or Rules Are For Rookies. Paper presented at the Flight Safety Foundation Fall Workshop; October 2005.

4. Hudson, P., Verschuur, W., Parker, D., Lawton, R. & Van der Graaf, G. (2004). Retrieved 2005, Bending the Rules: Managing Violations in the Workplace http://www.energyinst.org.uk/heartsandminds/docs/bending.pdf.

5. Helmreich, R. L. (1998). Culture, Threat, and Error: Assessing System Safety. Paper presented at the Safety in Aviation: The Management Commitment: Proceedings of a Conference. Royal Aeronautical Society, London.

6. Reason, J., Parker, D. & Lawton, R. (1998). Organisational Controls and Safety: The Varieties of Rule-Based Behaviour. Journal of Occupational and Organisational Psychology 71(4), 289-304.

7. Huntzinger, D. (1994). The Motivating Factors and Perceptions of Risk Associated with Intentional Rule Breaking Among Aviators. Ph.D. Thesis, The Union Institute, Cincinnati, OH.

8. Wilde, G. J. S. (1994). Retrieved 2005, Target Risk, http://psyc.queensu.ca/target/