Addressing the Challenge of Failure to Follow Procedures

by Bill Johnson, Ph.D., FAA and Kylie Key, Ph.D., FAA Aviation Safety

Most aviation maintenance workers and their managers know the importance of procedures. They know that procedures are often based on regulations and they know how to follow them. Even so, a very high percentage of safety lapses are triggered by a failure to follow procedures (FFP).

That’s why the FAA launched a three-year research and development project to investigate FFP events and develop a web-based training program to prevent them. The online training program is based on lessons learned from approximately 150, 90-minute interviews with Aviation Maintenance Technicians (AMTs), supervisors, and procedure writers. Researchers asked interviewees to describe a FFP event and its contributing factors, and/or rate the effectiveness of good practices for reducing FFPs.

A very high percentage of negative safety events are triggered by a failure to follow procedures (FFP).

An important finding from the interviews was that FFPs don’t usually arise from a lack of knowledge or from poor quality in procedural documents. Mechanics know the regulations and the importance of using the written technical procedures. Procedure writers also know how to do their job. So knowledge is not enough to stop FFPs.

FFP events we studied frequently arose from task familiarity, interruptions and distractions, time pressure and competing priorities, and group norms of deviating from procedures. In short, FFPs are largely driven by an industry culture of completing perceived safe and quality work, as quickly as possible, to the neglect of strict procedural compliance. Consequently, the best way to address FFPs is to address the general industry culture regarding the design and use of procedures.

So Now What?

The practical products from this research project were designed to change daily attitudes and behaviors about explicit use of procedures. To accelerate this culture change, the researchers launched a free, 30–45 minute training course called “FFP: The Buck Stops with Me.” This course emphasizes the message that, since FFP is everyone’s problem, each of us should take responsibility for ensuring procedural compliance. No more passing the buck! The training introduces 11 Attributes of Safety Champions (see Figure 1), and concludes with an invitation for trainees to sign a Safety Champion pledge.

Figure 1. Safety Champion Attributes

The course also comes with before-and-after procedure following task cards for AMTs, supervisors, and procedure writers. Companies can print and promote the before-and-after procedure following task cards to be worn on employee badge lanyards. You can find all printing specifications at under the “Training & Tools” tab.

The “The Buck Stops with Me” course helps aviation maintenance personnel understand that 100-percent procedural compliance relies on a healthy safety culture.

We launched the course in October 2018, and it has already attracted nearly 14,000 users. Some companies have adopted it as their recurrent training program, and we expect more to follow suit. If you haven’t already checked it out, we strongly encourage you and your colleagues to take the course at

Small investments can lead to big changes in the long run. Monetary commitment is not enough. Training and task cards are only the beginning. Now, industry must re-energize its commitment to following procedures. Everyone from senior management, organized labor units, individual workers, and government must commit to addressing the FFP challenge. Inadequate procedures, regardless of the reason, must be reported and revised in a timely manner. If FFP is everyone’s problem, then it is everyone’s opportunity to improve. Please do your part!

Kylie Key, Ph.D., is an Engineering Research Psychologist for the Flight Deck Human Factors Research Laboratory at the FAA’s Civil Aerospace Medical Institute (CAMI).

William B. Johnson, Ph.D., is FAA Chief Scientific and Technical Advisor for Human Factors in Aircraft Maintenance Systems

This article was originally published in the July/August 2020 issue of FAA Safety Briefing magazine.



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