FAA Office of Aerospace Medicine
Civil Aerospace Medical Institute

Report No: DOT/FAA/AM-22/01

Title and Subtitle: Procedural Noncompliance in Aviation Maintenance: A Multi-Level Review of Contributing Factors and Corresponding Mitigations

Report Date: January 2022

Authors: Key, K, Schroeder, D, Durham, J, Choi, I, Hu, P, Avers, K

Abstract: Compliance with approved procedures is an essential part of ensuring safety. Despite the continued training and focus on procedure following, Failure to Follow Procedures (FFP) is one of the most pervasive human factors issues in aviation maintenance. To prevent the recurrence of FFP, this report reviews the scientific literature regarding the contributing factors to and potential mitigations for FFP in aviation maintenance. Consistent with the HFACS-ME framework, the report describes human error as a multi-level issue consisting of an interaction between the organizational context (culture, resources), supervisory conditions, working environment, and maintainer conditions (mental and physical state; crew coordination). Expanding upon the HFACS-ME framework, the current report proposes evidence-based recommendations and potential mitigations for the contributing factors at each level of the organization. Evidence suggests that implementation of these mitigations may reduce the FFP rate and improve safety in the aviation maintenance industry.

Key Words: failure to follow procedures (FFP), compliance, aviation maintenance, human factors

No. of Pages: 78