Why do we STILL not Follow Procedures?

Abstract

Even though in aviation maintenance, as in many other regulated industries, written procedures are mandated, we still see “Failure to Follow Procedures” as a contributing factor in too many event/ incident/ accident reports (Drury and Johnson, 2013). This paper details an aviation maintenance project that seeks to find recurring patterns of events, contributing factors to these events, and potential good practices that, if followed, will reduce the incidence and/or severity of these events. Over 100 reference sources were examined to provide a framework of event classification. A total of 154 events selected for procedures content from ASRS was analyzed, plus 93 NTSB reports of failure to follow procedures accidents. Hierarchical classification schemes for contributing factors and potential good practices were derived and compared across sources. The main findings were that both design of the procedure itself and the organizational milieu surrounding its use had significant potential for reducing these adverse events.