FOD Prevention Banner  (Follow Procedures The Buck Stops Here) Safety Course

The minimum compliance standard in aviation is zero violations. However, while industry personnel understand the importance of using and following written technical procedures; not following procedures continues to be among the most ingrained safety issues in aviation maintenance.

Why is this behavior so pervasive? It is an unfortunate feature of our culture that the outcome is usually more important than the process. When a violation goes well, we consider it an exercise of initiative. When it goes wrong, it is due to lack of character. So, if you get away with it you are a hero, and if not, you are the goat.

Violating is very dangerous. In a study by the University of Illinois, “Human Error and General Aviation Accidents: A Comprehensive, Fine-Grained Analysis Using HFACS” (May 2005) it was found that fatal accidents were greater than four times more likely to be associated with violations than non-fatal accidents.

One reason violating is dangerous is that people who violate seem to assume that everyone else is compliant. Violations absorb the safety margin, so if someone else makes a mistake, or violates at the same time, the outcome of this grim combination can be tragic.

Violating is so dangerous that we consider it a moral issue. We use terms like failure, negligence, blame, and guilt to describe those who violate. When a mishap occurs, it is usually easy to find someone who did not follow a procedure. At this point, it is our habit to blame the culprit. After all, someone needs to balance the scales of justice.

Who generally gets the blame? Of course, it must be the mechanic…right? Or, does the blame lie elsewhere, maybe with inspectors who might also overlook procedures. Often people blame the manager or supervisor who rush a task to meet a production schedule, or flight departure time. Some blame the manufacturers who produce documentation that is incomplete, difficult to use, or just too complicated. Procedure writers may blame the legal department for requiring too many cautions and warnings. The lawyers often blame the regulators for burdensome and unreasonable requirements. The truth of the matter is that everyone is to blame for failure to follow procedures, but there is good news. If everyone is part of the problem, they can also be a part of the solution. When you, whether you are a top airline executive, or a newly hired mechanic commit to a culture of continuous procedure following you will break the cycle of passing the buck for failing to follow procedures.

Dr. Bill Johnson, the FAA’s Chief Scientist for Maintenance Human Factors has developed a Web-based Training (WBT) course emphasizing safety culture and procedural compliance. This web-based training is the first of its kind to address the organizational culture of procedural non-compliance.  To learn how you can champion a commitment to follow procedures every time, visit and take the new course. “Follow Procedures: The Buck Stops Here”.

To learn more contact:
Guy Minor
FAA Safety Team (FAASTeam)
General Aviation and Commercial Division, AFS-850

FAASTeam Notice
Type: General Information
Notice Date: Wednesday, November 7, 2018
Notice Number: NOTC8196

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