TEM

1. Standard Operating
Procedures
Why do pilots not (always)
follow procedures?

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Procedures and SOPs
 To ensure effective compliance with published procedures and
SOPs, it is important to understand why pilots intentionally or
inadvertently deviate
 In most cases of deviation, the procedure that was followed in
place of the correct one seemed to be appropriate, considering
the information available
constitute the reference
for crew standardization and provide the working
environment required for enhanced and efficient
crew communication and coordination.

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Purposes of Procedures and SOPs
 Establish a common action project
 Reduce ambiguities and error risks
 Guarantee better task sharing
 Reduce crew workload
 Facilitate mastering actions and errors
 Contribute to situational awareness
 Reduce risks of conflicts
• ICAO Air Nav Services on A/C Operations
• FAA AC 120-71 + JAR-OPS 1.104
• IATA HFWG on “Adherence to SOP”

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Outline and Objective of the Presentation
 In earlier times:
Incidents and accidents were linked with catastrophic structural, engine or
system failures or with bad weather
Technical evolutions led to a decline of catastrophic failures
 At present:
Primary and contributory causes are mostly crew-related (two out of three)
 Non-adherence to procedures and SOPs as a threat:
Sources on human error abound: ICAO ADREP, FSF ALAR
Line operations safety audits (LOSA) and reporting confirm the rise of
procedural errors

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Nonadherence to Procedures
Is it really such an issue?
Factors in aircraft accidents 1970-1997
5%
11%
12%
15%
35%
42%
69%
ATC
Maintenance
Aerodrome
Power plant
Environment
Aircraft
Crew
ICAO ADREP

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Line Operations Safety Audit (LOSA)
Error Frequencies
6
5
6
29
54
0 20 40 60 80 100
Decision
Proficiency
Communication
Procedural
Noncompliance
Percent Frequency
UTX
But what about consequences?

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The Rise of Procedural Noncompliance
 Procedures are being increasingly written to shape crew behavior toward
what is considered to be safe
 “Hard” design combined with “soft” procedural defenses encourage
deviations
 The overabundance of SOPs mostly stems from:
– the need to adapt to constantly changing habits and policies
– the need to increase capacity and efficiency of operations
– the need to manage an increasingly complex environment
 Understanding noncompliance can be done from a variety of angles:
Cognitive, Behavioral, Ergonomic,
Safety Management and Data Analysis

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23 Types of Procedural Nonadherences
 No perception of relevant information (input)
 Misperception of information (pattern matching)
 Procedural design (input, interpretation)
 Procedural experience/training (long-term memory)
 Cultural aspects (influencing factors)
 Personality aspects/attitudes (influencing factors)
 Situational factors (influencing factors)
 Decision-making heuristics (decision making)
 CRM (awareness and attention management)
Further reduced to nine subcategories for remedial action:
TRAINING OPERATIONS
DESIGN

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The Behavioral Approach: Errors and Violations
M
O
T
I
V
A
T
I
O
N
POWERFULNESS
ATTITUDES
SOCIAL
NORMS BEHAVIOR
INTENTION
EXPECTATION
PLANNING
CONSEQUENCE
OPPORTUNITIES
EXTERNAL
GOALS
Verschuur and Hudson

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Eight Types of Procedural Nonadherence
 Four types of violations based on performance levels:
– routine violations: common practice becoming group norm
– optimizing violations: challenge when rules are too restrictive
– situational violations: dictated by immediate environment
– exceptional violations: unusual or unfamiliar circumstances
 Four types of errors based on operational taxonomy:
– procedural errors: correct intention/incorrect execution
– communication errors: incorrect transmission/interpretation
– proficiency errors: insufficient knowledge and/or skill
– operational decision errors: unnecessary increase in risk
Intentional “violations” and “unintentional noncompliance” (errors)

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EVENT RECOGNITION PROCEDURE REMARKS
WARNING EXECUTION
LOSS OF IRS DATA "ATT" FLAG IS NOT SOPs FOR NOT MOVING "ATT" WARNING WILL
AFTER TAKEOFF DISPLAYED ON PFD, WITH THE AIRCRAFT DURING IRS BE DISPLAYED AS
A 300 - 600 HONEYWELL IRU, IF A/C IS MOVED ALIGNMENT SOON AS EXCESSIVE
JUST AFTER PFD DISPLAY MOTION DETECTED
COMES ON
RETURN TO GATE FQI LESS THAN REQUIRED ON PREVIOUS LEG, ARRIVAL FOB
ALT TO THR CLB / NOT CHECKED VERSUS DEPARTURE
OPEN CLB WITH FOB LESS TRIP FUEL PER SOP
AIRCRAFT DESCENDING
AT IDLE
A 320
BRUTAL DOOR ECAM DISPLAY RESOLUTION? SOP STATE "CHECK DIFFERENTIAL
OPENING AT GATE PRESSURE IS ZERO…"
A 300 - 600
EVENT RECOGNITION PROCEDURE REMARKS
CREW DIAGNOSIS EXECUTION
NAVIGATION NO F-PLN ABNORMALITY NO FOR F-PLN CROSSED
DEVIATION AFTER NOTED DURING COCKPIT CHECK ?
GO AROUND PREPARATION
NAV DEVIATION DETECTED BY ATC FOR NAV MONITORING
DURING SID ?
NAV LINE ANOMALY
OBSERVED ON PFD
RADAR VECTORS ISSUED TO
RECOVER F-PLN AT "TO WPT"
Absence of Recognition Leading
to Nonadherence to Procedures

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Recognition Issue Leading to Nonadherence
EVENT RECOGNITION RECOGNITION PROCEDURE REMARKS
WARNING CREW DIAGNOSIS EXECUTION
ENG TAIL PIPE FIRE NO ENG FIRE WARNING ENG TAIL PIPE FIRE ENG FIRE DRILL APPLIED
A 310 TRIGGERED REPORTED BY ATC ENG TAIL PIPE FIRE NOT APPLIED
ENG FLAMEOUT DUE UNDETECTED FUEL OUTR TANK QRH PROCEDURE NOT FUEL FEED
TO FUEL STARVATION AUTOFEED FAULT LOW LEVEL FOLLOWED FROM OUTR TANK
A 300 - 600 DISREGARDED AS SUSPECTED FOLLOWING FAULT
SPURIOUS
THROTTLE LEVER THROTTLE LEVER NOT AT IDLE AIRCRAFT PUSHED TRACTOR NON COMPLIANCE WITH 6 EVENTS SO FAR
NOT AT IDLE NOT SET AT IDLE ABOUT 10 FEET BACK SOPs FOR SETTING THR
DURING MES MESSAGE CREATED LVR TO IDLE BEFORE MES
A 320
UNWARRANTED IFSD DECREASING OIL PRESSURE MISUNDERSTANDING UNWARRANTED ENGINE TYPICAL CASE OF
BASED ON DECREASING BUT NO LOW OIL PRESSURE OF OIL PRESSURE AND LOP SHUTDOWN HURRIED REACTION
OIL PRESSURE WARNING INDICATIONS CLIMB PHASE
A 320

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Procedural Subtlety Leading to Nonadherence
EVENT RECOGNITION PROCEDURE PROCEDURE CREW ACTION REMARKS
CREW DIAGNOSIS CONTENTS EXECUTION
VIOLENT OPENING FAILURE TO RECOGNIZE "ON GROUND EMER / EVAC" PROC FAILURE TO COMPLETE DOOR OPENING WITHOUT CAB PRESS
ON GROUND THAT A/C WAS STILL DOES NOT POINT THAT RAM AIR "CAB PRESS MAN CTL" POSITIVE CONFIRMATION DIFFICULTIES +
A 300 - 600 PRESSURIZED EFFECT IS WITH CAB PRESS PROC BEFORE CALLING EVACUATION OF DEPRESSURIZATION LAV / CARGO
IN AUTO ONLY AND DOING THE CRM AND WORKLOAD ISSUE SMOKE WARNINGS
"ON GROUND EMER / EVAC" PROC
EVENT PROCEDURE CREW REMARKS
EXECUTION ACTION
ENG FAILED TO FOT AND FCOM
REACH TAKE OFF ENG NOT SHUTDOWN ENG SET AT IDLE ONLY REVISION
POWER DUE TO PLANNED
FUEL LEAK
A 320
EVENT RECOGNITION CREW REMARKS
WARNING ACTION
RTO DUE TO ECAM WARNING TRIGGERED BY
ENGINE PREVIOUS CREW AWARENESS
THRUST LOSS MESSAGE A.ICE ENG LATE RTO ACTION NEED TO AVOID SUCH
A330 VALVE OPEN SITUATIONS IN ANY
ECAM AT 80 KT / FUTURE DESIGN
A. ICE ENG 1 VALVE OPEN CREW RTO AT 130 KT
AWARENESS MESSAGE
ACTIVATED AT HOLDING POINT
AWARENESS MESSAGE AND
ECAM WARNING
NOTE TO BE ADDED IN FCOM
TO ANTICIPATE
INTERLINK BETWEEN CREW
PROCEDURE
CONTENTS
RECOGNITION
CREW DIAGNOSIS
LOW POWER
HIGH FUEL LOW
VISIBLE FUEL LEAK
FROM ENGINE

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Rushed Action Leading to Nonadherence
EVENT RECOGNITION PROCEDURE CREW REMARKS
CREW DIAGNOSIS EXECUTION ACTION
ALT DEV IN TURBULENCE TURBULENCE READINESS IF TURB WAS FORECAST SP/ALT HLD CREW DISCONNECTED AUTOPILOT
WITH PROFILE MODE FROM FORECAST SHOULD HAVE BEEN PREFERRED TO RATHER THAN LEAVING PROFILE
A 300 - 600 PROFILE MODE (REVERSION TO SPD/ALT HLD)
AP + A/THR + PITCH TRIM NONE SOPs NOT COMPLIED WITH AP DISCONNECTION BY STICK
DISCONNECTION + FOR PREVENTION AND RECOVERY FORCE SUSPECTED
ALT DEV IN TURBULENCE MANUEL RECOVERY AND
A 310 AUTOPILOT REENGAGEMENT
TURB ENCOUNTER POSITIVE QRH NOT APPLIED FOR OVERSPEED SPEED BRAKES EXTENSION TRAINING ISSUE ?
AND STALL PREVENTION AND RECOVERY AS SPEED UP TO MMO
A 310 CREW RESISTED THE AUTOPILOT A-THR REDUCING TRUST
AT FL 350
SPEED DECREASING TO
STALL WARNING
OUT OF TRIM
CONDITION CORRECTED
BY F/O PNF
AP REENGAGED
RECOVERY AT FL330
COLLISION WITH BREAK PRESSURE CREW FAILURE TO CONFIRM PARKING
JETWAY ON ARRIVAL NOT VERIFIED BRAKE PRESSURE BEFORE
A 320 RELEASING PEDALS AND SHUTTING RELEASING PEDALS AND SHUTTING
ENGINES DOWN, PER SOP ENGINES DOWN PEMATURILY

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Undue Interpretation Leading to Nonadherence
EVENT RECOGNITION PROCEDURE CREW REMARKS
CREW DIAGNOSIS EXECUTION ACTION
ENGINE FIRE BECAUSE PARAMETERS WAS ECAM DISREGARDED SPURIOUS WARNING SPURIOUS WARNING
WARNING AND IFSD NORMAL, EXCEPT OQ "XX" SHOULD BE CORRECTED SHOULD BE CORRECTED
PERFORMED 54 CREW CONCLUDED TO SPURIOUS EFFECTIVELY AND EFFECTIVELY AND
MINUTES LATER WARNING DESPITE 2 VISUAL QUICKLY TO PREVENT QUICKLY TO PREVENT
A 330 INSPECTIONS CREW DISREGARDING CREW DISREGARDING
WARNING ACTIVATION WARNING ACTIVATION
IFSD WHEN OP "XX"
AFTER 54 MINUTES
EVENT RECOGNITION PROCEDURE CREW REMARKS
WARNING EXECUTION ACTION
IFSD BASED ON STEP DECREASE OF ENGINE DECREASING OIL QTY OR OIL QTY PRECAUTIONARY IFSD NO OIL LEAK
DECREASING 1 OIL QTY ADVISORY CALL ONLY FOR + FOUND BUT …
OIL QTY MONITORING OF OIL PRESS DIVERSION 14 QTS ADDED !
A 321 AND OIL TEMP

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From Recognition and Execution to ...
EVALUATION
of Constraints
INTERPRETATION
of Consequences
IDENTIFICATION
of the State of a System
SEARCH
for Information
DETECTION
of Abnormal Conditions
Adapted from
Rasmussen (1986)
DEFINITION
of a Task
FORMULATION
of a Procedure
EXECUTION
of Actions
Skills
Rules

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From Machine Minding to Decision Making
From a two-stage to a three-stage process
Wave of Recognition • Perception of Warnings
• Interpretation by Crew
Wave of Execution
• Procedure Specification
• Procedure Execution
Wave of Decision Making
• Evaluation of Options
• Expectation of How to Do
• Formulating the Intention

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Causal Factors in Approach and Landing Accidents
 Inadequate decision making 74%
 Omission of action or inappropriate action 72%
 Nonadherence to criteria for stabilized approach 66%
 Inadequate CRM practice
(coordination, cross-check, backup) 63%
 Insufficient horizontal or vertical
situational awareness 52%
 Inadequate or insufficient understanding
of prevailing conditions 48%
 Slow or delayed action 45%
 Flight handling difficulties 45%
 Deliberate non-adherence to procedures 40%
 Incorrect or incomplete pilot/controller communication 33%
 Interaction with automation 20%
 No go-around when required 17%

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 Pilots use recognitive processes in the deployment
of procedures, which may be accompanied by errors
– Effective crews apply judgment to direct decision making
 Pilots’ natural risk-evaluation strategies help them to distinguish
consequential errors from benign ones
– This hinges on knowing how to trade off a variety of human factors
 Applying procedures can be repetitive, rather than sequential, even
under heavy time pressure
– Effective crews avoid rushed overreactions, if at all possible
Conclusions

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Conclusions (continued)
 The challenge of the future is to develop decision aids,
cockpit and training systems that support rather than hinder the way
good decision makers make decisions
– Experienced crews tap a vast reservoir of alternatives
 These procedures and SOPs should enable pilots to
exercise discernment and good decision making
– They should be simple and accurate and with easy-to-assess
consequences
 There is an enlarged role for pilots to be trained in
decision making while using relevant procedures
Simplicity
Accuracy