Procedural Non-Compliance

There are many maintenance-related safety events that are the result of employees not following prescribed procedures for completing a task – known as Failure to Follow Procedures (FFP). The requirement is straightforward, but complying with it in practice is not. Despite the continued training and focus on procedure following, FFP is one of the most pervasive human factors issues in aviation maintenance, contributing to a majority of all accidents/incidents. The historic response to FFP was focused on the employee, which led to a blame cycle of training or disciplinary action. Although blaming-and-training can be faster and easier in the short term, experts have found that person-centered mitigations like “blame-and-train” do not effectively reduce FFP. Instead, a systematic approach is needed, where contributors at all levels of the organization are addressed.

Training and Tools

Follow Procedure Training: The Buck Stops with Me

Aviation Maintenance Technicians (AMTs) and other industry personnel have the technical knowledge to safely perform their jobs, so why does failure to follow procedure (FFP) remain a leading cause in administrative actions? Reducing FFP events and improving an organization's safety culture require continuous effort and a shared commitment to creating a culture of procedure following and becoming safety champions. Workers at all levels must work together and be able to prompt one another to follow procedures at all times. We must all understand that when it comes to FFP, the Buck Stops With Me! 

Follow Procedure Training

Select the file below to download the Follow Procedures Training to your computer for use within your company's learning management system. Once downloaded, unzip and extract files to a designated folder. Select the "Index" file to run the training. If you need help, please contact Kim Brewer.

Before-and-After Procedure Following Task Cards

Improvement requires continuous effort and a shared commitment to creating a culture of procedure following; Before-and-After Procedure Following Task Cards are tools to help in that effort. These cards remind personnel of important steps to complete before, during, and after performing tasks. Cards are laminated and designed to hang from a lanyard. The FAA's Aerospace Human Factors Research Division has a small number of cards available for distribution; however, larger organizations may choose to print cards for their AMTs, Supervisors and Managers, and Procedure Writers.

Some companies may also elect to personalize the cards by replacing the FAA with their company logo. When ordering, please consider the number of cards you will need for each position prior to ordering. For example, your organization may have 100 AMTs, 10 Supervisor/Managers, and only 5 Procedure Writers. Select the links below to download the Before-and-After Procedure Following Task Cards to your computer.

Links

  • Procedural Compliance - Handbook (PDF) 
    This handbook is a compilation of countermeasures that can be used to build a systematic response to FFP where contributors at all levels of the organization are considered and mitigated.
     
  • Design and Use of Technical Information (PDF) 
    This activity, started in 2013, address the variety of challenges associated with the design and use of technical instructions. “Failure to follow the check list or procedures” applies to all aviation environments. This issue is repeatedly identified as a significant contributing factor in aviation maintenance events and accidents. This research includes all maintenance documentation for all aircraft categories and associated systems.  
     
  • Failure to Follow Procedures Contributing Factors (PDF) 
    This document contains some of the most common behaviors and attitudes that contribute to FFP risk. List 1, shown on the next page, provides example of FFP behaviors. Then, List 2 details the organizational or personal attitudes/(in)actions that likely cause the List 1 behaviors.
     
  • Failure to Follow Written Procedures (bts.gov)
    Most tasks in aviation have a mandated written procedure to be followed specifically under the Code of Federal Regulations (CFR) Part 14, Section 43.13(a). However, the incidence of Failure to Follow Procedure (FFP) events continues to be a major issue in aviation maintenance. This report details the results over 100 literature sources to identify human factors. Results showed that the top three areas of concern were the validity and availability of the procedure documentation, the difficulty of the task being performed, and the organizations social rules/norms.
     
  • Failure to Follow Procedures: Deviations are a significant Factor in Maintenance Errors. (PDF) 

 

 

Last updated: Tuesday, October 31, 2023