Why Do Good People Violate Procedures?
A Common Sense Look at Why Some Mechanics Are Prone to Bend the Rules
By Guy Minor, National FAA Safety Team
One weekend on a revenue flight, an aircraft enters a fog bank at a very low altitude. The pilot begins an immediate 180-degree turn to exit the fog. During the turn, the aircraft descends into the water and lands hard. Fortunately, the accident does not hurt anyone and just damages a very expensive turbine-powered floatplane.
Later, the operator sends a maintenance crew out to inspect the aircraft. They find the engine undamaged, but the impact has bent the fuselage. What to do? The crew is standing on the floats of a $1.5 million aircraft, bobbing about in the water. They understand it is against the rule to fly a damaged aircraft, but they also have the expertise to know the aircraft is safe to fly. They do not want to risk anchoring the aircraft overnight or tying it up to a stranger’s dock. Disassembling it will take too long, and transporting the aircraft by ground will most certainly damage it even more.
Procedure violation is not really about being a bad person. Reality is much more complex than that.
It will be dark soon, and a ferry permit takes time to negotiate, so it will delay their recovery. After all, it’s just a piece of paper, right? Its only purpose is to ensure that someone with expertise certifies the aircraft is in a safe condition to make the intended flight. With all this in mind, the team makes the decision to fly the aircraft home.
Later, when inspectors arrive to investigate the accident, they are surprised to find the aircraft at its base, safely in a hangar. You can imagine the conversation. Where was the accident? It happened out in the water. How did the aircraft get back home? We flew it back. You flew a damaged aircraft? May we see the ferry permit? You get the idea.
In a study called “Bending the Rules: Managing Violation in the Workplace,” Patrick Hudson, et al. (2005) points out that most people seem compliant, but they are willing to violate. He also identified four indicators of violation from his research on rule violation by offshore oil drilling crews: 1) expectation that the rules will have to be bent to get the work done, 2) the feeling that one has the ability and experience to do the job without slavishly following the procedures, 3) seeing opportunities for short cuts or to do things better, and 4) inadequate advance preparation, leading to working on the fly and solving problems as they arise.
So how do these four principles apply to the story of the floatplane? Did the recovery crew feel that bending the rules was required to get the job done? Probably, since it would have taken more time than they had available to wait for the permit. Waiting for a ferry permit would have delayed the work until it was too dark to use anyway. The problem was that even though they had made decisions based on the information at hand, in hindsight, they had not planned well prior to departing home base.
Put yourself in their shoes. Events tend to unfold one small piece of information at a time. More than likely, the indications prior to departing to inspect the aircraft were that the accident had damaged the aircraft too much for it to be ferried, so it is understandable why they did not obtain a ferry permit before departing. They were under intense pressure to get the aircraft to safety. The aircraft was too valuable to allow it to spend the night on the water. It was also much quicker to fly the aircraft home than disassembling it and trucking it home. This plan avoided the damage caused by transporting the plane by ground. The aircraft would be back flying its route in days, not weeks or months. This maintenance crew is the best floatplane crew in the world. They certainly possess the expertise to know if an aircraft is safe for a ferry flight. The outcome of the situation is that they were right; the aircraft did make it home uneventfully, just not legally.
Why Good People Do Wrong Things
Understanding why good people violate procedures is the first step to understanding what to do to prevent it. British psychologist James Reason divides unsafe acts into two categories: errors and violations. The prevailing doctrine in our industry is that the main difference between error and violation is intent. People do not intend to err, but violations are intentional. This makes the decision to violate a matter of choice, and if it is a matter of choice, then we must take responsibility for our choices. Since violating is very dangerous, we naturally attribute violation to the aviator’s lack of character. Good guys and bad guys. Is it really that simple, though?
Certainly, there are people in aviation who are less than ethical. However, it is a pathological person who would think, “I’m going to set out today to make a mistake that will hurt customers or damage equipment. Maybe I’ll ruin my career or kill myself today.” People just do not think like that. When presented with a list of options, they struggle to pick the best one every time. For that reason, procedure violation is not really about being a bad person. Reality is much more complex than that. It is an uncomfortable fact that the last people you would ever expect to violate the rules, people who are hard-working, loyal, sharp technicians are the ones who commit the most violations.
We tend to avoid discussing the organizational conditions promoting violations. It is more common to attribute the source of violations to the violator’s lack of character. This point of view ignores the possibility of violations that are more or less well intended, i.e., violations committed out of necessity or under pressure. Many of the same conditions that cause mistakes also cause violations, conditions such as low assertiveness, poor planning, lack of resources, poorly written procedures, poorly trained procedures, the list goes on.
Violating with Good Outcome
Situations such as the floatplane accident are far more common than we care to admit. The maintenance technician’s world involves the expectation to “follow the rule to the letter, but use your common sense.” New technicians who try to follow procedures learn very quickly that they need to use common sense and sometimes trade ethics for efficiency, or they will face frustrated managers who view them as inefficient, unproductive, and subject to termination. If the outcome of any particular task is good, managers and peers praise violating technicians as creative, efficient, and productive. However, if the task has a tragic outcome, the technician is a rule-breaker, negligent, and culpable.
We cannot as an industry change for the better if we continue to relegate violation to the shadow world. We need to drag it out where we can see it and deal with it. It is time to discuss violations openly. It is time to acknowledge that violators are not a criminal class. It is time to understand the systemic pressures that influence good people to violate and teach managers to control and recognize these pressures.
So what is the solution? How do we control organizational conditions that influence unsafe acts? Sanne and Dekker point the way.
“We can make progress on safety once we acknowledge that people themselves create it, and we begin to understand how. Safety is not inherently built into systems or introduced via isolated technical or procedural fixes. Safety is something that people create, at all levels of an operational organization … Safety is the emergent property of a system of people who invest in their awareness of potential pathways to breakdown and devise strategies that help forestall failure.”
Managers are most in control of the organizational conditions that influence unsafe acts, so it would be helpful for aviation managers to be good managers. The focus of aviation maintenance technician schools is to prepare students to be technical experts, not managers or leaders. The typical floor mechanic learns leadership from their parents, sports programs in school, scouting, and of course, supervisors they have known. Some of this training is good; some not so much.
Perhaps after their technical training, we should teach maintenance technicians, who are already technical experts, the non-technical skills they need to create safety and reduce unsafe acts. Mechanics need leadership skills such as assertiveness, planning, time management, business writing, public speaking, safety ethics, and labor law, to mention just a few helpful topics. Teaching these non-technical skills along with the more technical skills such as safety management systems, human error fundamentals, and performance rules would help equip managers to operate with more confidence and assertiveness in the boardroom and on the shop floor.
Guy Minor is an FAA aviation safety inspector and FAA Safety Team airworthiness program manager.