Standard Operating

Procedures

Why do pilots not (always)

follow procedures?

Procedures and SOPs

constitute the reference
for crew standardization and provide the working
environment required for enhanced and efficient
crew communication and coordination.

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

Non Adherence to Procedures

Page 2

1.PQ_03_Vis_Issue1

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

Non Adherence to Procedures

Page 3

1.PQ_03_Vis_Issue1

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

Non Adherence to Procedures

Page 4

1.PQ_03_Vis_Issue1

Nonadherence to Procedures
Is it really such an issue?
Factors in aircraft accidents 1970-1997
Crew

69%

Aircraft

42%

Environment

35%

Power plant

15%

Aerodrome

12%

Maintenance

11%

ATC
Non Adherence to Procedures

5%

ICAO ADREP
Page 5

1.PQ_03_Vis_Issue1

Line Operations Safety Audit (LOSA)

Error Frequencies

But what about

consequences?
Non Adherence to Procedures
Page 6

UTX
1.PQ_03_Vis_Issue1

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

Non Adherence to Procedures

Page 7

1.PQ_03_Vis_Issue1

23 Types of Procedural Nonadherences

Further reduced to nine subcategories for remedial action:

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)

TRAINING
DESIGN

Non Adherence to Procedures

Page 8

OPERATIONS
1.PQ_03_Vis_Issue1

The Behavioral Approach: Errors and Violations

M
O
T
I
V
A
T
I
O
N

ATTITUDES

EXTERNAL
GOALS

CONSEQUENCE

INTENTION

SOCIAL
NORMS

PLANNING

BEHAVIOR

EXPECTATION
POWERFULNESS

OPPORTUNITIES

Verschuur and Hudson

Non Adherence to Procedures

Page 9

1.PQ_03_Vis_Issue1

Eight Types of Procedural Nonadherence

Intentional violations and unintentional noncompliance (errors)

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

Non Adherence to Procedures

Page 10

1.PQ_03_Vis_Issue1

Absence of Recognition Leading

to Nonadherence to Procedures
EVENT

RECOGNITION
WARNING

PROCEDURE
EXECUTION

LOSS OF IRS DATA

AFTER TAKEOFF
A 300 - 600

"ATT" FLAG IS NOT

DISPLAYED ON PFD, WITH
HONEYWELL IRU, IF A/C IS MOVED
JUST AFTER PFD DISPLAY
COMES ON

SOPs FOR NOT MOVING

THE AIRCRAFT DURING IRS
ALIGNMENT

RETURN TO GATE
ALT TO THR CLB /
OPEN CLB WITH
AIRCRAFT DESCENDING
AT IDLE
A 320

FQI LESS THAN REQUIRED

ON PREVIOUS LEG, ARRIVAL FOB

NOT CHECKED VERSUS DEPARTURE
FOB LESS TRIP FUEL PER SOP

BRUTAL DOOR
OPENING AT GATE
A 300 - 600

ECAM DISPLAY RESOLUTION?

EVENT

RECOGNITION
CREW DIAGNOSIS

PROCEDURE
EXECUTION

NAVIGATION
DEVIATION AFTER
GO AROUND

NO F-PLN ABNORMALITY
NOTED DURING COCKPIT
PREPARATION

NO FOR F-PLN CROSSED

CHECK ?

NAV DEVIATION DETECTED BY ATC

FOR NAV MONITORING

DURING SID ?

n
o
i
it
n
g
o
ec
r
f
o
ce
n
e
s
b
a
is
t
ha
W

r
e
h
ot

a
n
a
th

to
n
i
p
tr a

?
r
o
g
i
r

REMARKS

f
o
k
c
a
l

"ATT" WARNING WILL

BE DISPLAYED AS
SOON AS EXCESSIVE
MOTION DETECTED

SOP STATE "CHECK DIFFERENTIAL

PRESSURE IS ZERO"

REMARKS

NAV LINE ANOMALY

OBSERVED ON PFD

RADAR VECTORS ISSUED TO

RECOVER F-PLN AT "TO WPT"

Non Adherence to Procedures

Page 11

1.PQ_03_Vis_Issue1

Recognition Issue Leading to Nonadherence

EVENT

ENG TAIL PIPE FIRE

A 310

ENG FLAMEOUT DUE

TO FUEL STARVATION
A 300 - 600

THROTTLE LEVER
NOT AT IDLE
DURING MES
A 320

n
a
c
w
Ho

RECOGNITION
WARNING

RECOGNITION
CREW DIAGNOSIS

PROCEDURE
EXECUTION

REMARKS

MISUNDERSTANDING
OF OIL PRESSURE AND LOP
INDICATIONS

UNWARRANTED ENGINE
SHUTDOWN

TYPICAL CASE OF
HURRIED REACTION
CLIMB PHASE

?
e
c
n
e
r
NO ENG FIRE WARNING
ENG TAIL PIPE FIRE
ENG FIRE DRILL APPLIED e
dh
TRIGGERED
REPORTED BY ATC
ENG TAIL PIPE FIRE NOT a
APPLIED
al
r
u
d
ePROCEDURE NOT
UNDETECTED
FUEL OUTR TANK
QRH
FUEL FEED
c
AUTOFEED FAULT
LOW LEVEL
FROM OUTR TANK
ro FOLLOWED
p
DISREGARDED AS SUSPECTED
FOLLOWING FAULT
o
t
SPURIOUS
d
a
le
e
u PUSHED TRACTOR NON COMPLIANCE WITH 6 EVENTS SO FAR
s
THROTTLE LEVER NOT AT IDLE AIRCRAFT
is ABOUT 10 FEET BACK
NOT SET AT IDLE n
SOPs FOR SETTING THR
MESSAGE CREATED
LVR TO IDLE BEFORE MES
io
t
i
n
g
o
c
re

UNWARRANTED IFSD DECREASING OIL PRESSURE

BASED ON DECREASING BUT NO LOW OIL PRESSURE
OIL PRESSURE
WARNING
A 320
Non Adherence to Procedures

Page 12

1.PQ_03_Vis_Issue1

Procedural Subtlety Leading to Nonadherence

EVENT

RECOGNITION
CREW DIAGNOSIS

VIOLENT OPENING
ON GROUND
A 300 - 600

FAILURE TO RECOGNIZE
THAT A/C WAS STILL
PRESSURIZED

EVENT

PROCEDURE
CONTENTS

PROCEDURE
EXECUTION

"ON GROUND EMER / EVAC" PROC

FAILURE TO COMPLETE
DOOR OPENING WITHOUT
DOES NOT POINT THAT RAM AIR
"CAB PRESS MAN CTL"
POSITIVE CONFIRMATION
EFFECT IS WITH CAB PRESS
PROC BEFORE CALLING EVACUATION
OF DEPRESSURIZATION
IN AUTO ONLY
AND DOING THE
CRM AND WORKLOAD ISSUE
"ON GROUND EMER / EVAC" PROC

LOW POWER
HIGH FUEL LOW
VISIBLE FUEL LEAK
FROM ENGINE

EVENT

RECOGNITION
WARNING

RTO DUE TO
ENGINE
THRUST LOSS
A330

ECAM WARNING TRIGGERED BY

PREVIOUS CREW AWARENESS
MESSAGE A.ICE ENG
VALVE OPEN

an
c
w
o
H

REMARKS

?
e
c
n
re
e
dh
a
t
c
e
r
r
o
c
o
t
d
a
le
y
t
e
l
t
b
su
l
ra
u
d
e
c
o
r
p
RECOGNITION
CREW DIAGNOSIS

ENG FAILED TO
REACH TAKE OFF
POWER DUE TO
FUEL LEAK
A 320

CREW ACTION

A. ICE ENG 1 VALVE OPEN CREW

AWARENESS MESSAGE
ACTIVATED AT HOLDING POINT

Non Adherence to Procedures

PROCEDURE
EXECUTION

CREW
ACTION

ENG NOT SHUTDOWN

ENG SET AT IDLE ONLY

CAB PRESS
DIFFICULTIES +
LAV / CARGO
SMOKE WARNINGS

REMARKS

FOT AND FCOM

REVISION
PLANNED

PROCEDURE
CONTENTS

CREW
ACTION

REMARKS

NOTE TO BE ADDED IN FCOM

TO ANTICIPATE
INTERLINK BETWEEN CREW
AWARENESS MESSAGE AND
ECAM WARNING

LATE RTO ACTION

NEED TO AVOID SUCH

SITUATIONS IN ANY
FUTURE DESIGN

Page 13

ECAM AT 80 KT /
RTO AT 130 KT

1.PQ_03_Vis_Issue1

Rushed Action Leading to Nonadherence

EVENT

RECOGNITION
CREWDIAGNOSIS

PROCEDURE
EXECUTION

CREW
ACTION

REMARKS

?
g
in
k
a
m
n
o
i
is
c
e
d
e
r
u
t
a
em
r
p
n
ha
t
r
e
th
o
n
o
i
t
c
a
d
e
h
s
u
r
s
i
t
a
h
W

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

DISCONNECTION +
ALT DEV IN TURBULENCE
A 310

NONE

SOPs NOT COMPLIED WITH

FOR PREVENTION AND RECOVERY

AP DISCONNECTION BY STICK
FORCE SUSPECTED
MANUEL RECOVERY AND
AUTOPILOT REENGAGEMENT

TURB ENCOUNTER
AND STALL
A 310
AT FL 350

POSITIVE

QRH NOT APPLIED FOR OVERSPEED

PREVENTION AND RECOVERY
CREW RESISTED THE AUTOPILOT

SPEED BRAKES EXTENSION

AS SPEED UP TO MMO
A-THR REDUCING TRUST

TRAINING ISSUE ?

SPEED DECREASING TO
STALL WARNING
OUT OF TRIM
CONDITION CORRECTED
BY F/O PNF
AP REENGAGED
RECOVERY AT FL330

COLLISION WITH
JETWAY ON ARRIVAL
A 320

BREAK PRESSURE
NOT VERIFIED

Non Adherence to Procedures

CREW FAILURE TO CONFIRM PARKING

BRAKE PRESSURE BEFORE
RELEASING PEDALS AND SHUTTING RELEASING PEDALS AND SHUTTING
ENGINES DOWN, PER SOP
ENGINES DOWN PEMATURILY

Page 14

1.PQ_03_Vis_Issue1

Undue Interpretation Leading to Nonadherence

EVENT

RECOGNITION
CREW DIAGNOSIS

ENGINE FIRE
BECAUSE PARAMETERS WAS
WARNING AND IFSD
NORMAL, EXCEPT OQ "XX"
PERFORMED 54 CREW CONCLUDED TO SPURIOUS
MINUTES LATER
WARNING DESPITE 2 VISUAL
A 330
INSPECTIONS
IFSD WHEN OP "XX"
AFTER 54 MINUTES

PROCEDURE
EXECUTION

ECAM DISREGARDED

n
a
th
r
e
h
t
o

Page 15

REMARKS

CREW
ACTION

REMARKS

PRECAUTIONARY IFSD
+
DIVERSION

NO OIL LEAK
FOUND BUT
14 QTS ADDED !

?
g
in
k
a
m
SPURIOUS WARNING n
SPURIOUS WARNING
o
i
SHOULD BE CORRECTED
SHOULD BE CORRECTED
s
i
EFFECTIVELY
ecAND EFFECTIVELY AND
d
QUICKLY
TO PREVENT QUICKLY TO PREVENT
d
e
CREW
s DISREGARDING CREW DISREGARDING
a
i
b WARNING ACTIVATION WARNING ACTIVATION

n
o
i
t
EVENT
RECOGNITION
PROCEDURE
a
t
e
WARNING r
EXECUTION
p
r
e
t
n
i
e
IFSD BASED ON
STEP
u DECREASE OF ENGINE DECREASING OIL QTY OR OIL QTY
d
DECREASING
1 OIL QTY
ADVISORY CALL ONLY FOR
n
u
OIL QTYis
MONITORING OF OIL PRESS
t
Aa321
AND OIL TEMP
h
W
Non Adherence to Procedures

CREW
ACTION

1.PQ_03_Vis_Issue1

From Recognition and Execution to ...

EVALUATION
of Constraints
INTERPRETATION
of Consequences
Kn
ow
led
IDENTIFICATION
ge
of the State of a System
Knowledge
Kn
ow
led
ge
SEARCH
Rules
for Information
Rul
es
DETECTION
of Abnormal Conditions

Non Adherence to Procedures

Skills
Page 16

Adapted from
Rasmussen (1986)

DEFINITION
of a Task
FORMULATION
of a Procedure
EXECUTION
of Actions
1.PQ_03_Vis_Issue1

From Machine Minding to Decision Making

From a two-stage to a three-stage process

Wave of Recognition

Wave of Decision Making

Wave of Execution

Non Adherence to Procedures

Perception of Warnings

Interpretation by Crew

Evaluation of Options

Expectation of How to Do

Formulating the Intention

Procedure Specification

Procedure Execution

Page 17

1.PQ_03_Vis_Issue1

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%

Non Adherence to Procedures

Page 18

1.PQ_03_Vis_Issue1

Conclusion
sPilots use recognitive processes in the deployment
of procedures, which may be accompanied by errors

Pilots natural risk-evaluation strategies help them to distinguish

consequential errors from benign ones

Effective crews apply judgment to direct decision making

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

Non Adherence to Procedures

Page 19

1.PQ_03_Vis_Issue1

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

Accuracy

Simplicity

There is an enlarged role for pilots to be trained in

decision making while using relevant procedures

Non Adherence to Procedures

Page 20

1.PQ_03_Vis_Issue1