Failure to Follow Written Procedures

Details

• Creators:
  Drury, Colin G. ; Drury Barnes, Catherine ; Bryant, Michelle R
• Corporate Creators:
  Applied Ergonomics Group, Inc. ; Civil Aerospace Medical Institute
• Corporate Contributors:
  United States. Office of Aerospace Medicine
• Subject/TRT Terms:
  • Aviation law
  • Human factors in crashes
  • Human error
  • Aviation safety
  • Air transportation crashes
  • Vehicle maintenance
  • Procedures
  • Failure to follow procedures
  • human factors
  • aviation maintenance
• Publication/ Report Number:
  DOT/FAA/AM-17/17
• Resource Type:
  Tech Report
• Geographical Coverage:
  United States
• Corporate Publisher:
  United States. Office of Aerospace Medicine
• Abstract:
  Most tasks in aviation have a mandated written procedure to be followed specifically under the Code of Federal Regulations (CFR) Part 14, Section 43.13(a). However, the incidence of Failure to Follow Procedure (FFP) events continues to be a major issue in aviation maintenance. This report details the results of Phase 1 of a two phase effort. In Phase 1 we used over 100 literature sources to identify human factors causes of FFP events, developed a classification system of FFP events (TAPES), categorized 154 FFP events reported in the Aviation Safety Reporting System (between 1999 and 2015) and 94 National Transportation Safety Board Accident reports (between 2005 and 2015), and identified the common challenges facing aviation maintenance operators. Results showed that the top three areas of concern were the validity and availability of the procedure documentation, the difficulty of the task being performed, and the organizations social rules/norms. Phase 2 of this work will apply the developed classification system to FFP events taken from ; semi-structured interviews of aviation maintenance personnel. Results of Phase 2 will identify best practices for mitigation FFP events in aviation maintenance environments.
• Format:
  PDF
• Download URL:
  https://rosap.ntl.bts.gov/view/dot/35515/dot_35515_DS1.pdf
• File Type:
  [PDF - 1.36 MB]
• Collection(s):
  FAA Civil Aerospace Medical Institute ; US Transportation Collection
• Main Document Checksum:
  urn:sha256:f440c479da53e2ed8909b67c7d283c22ef76f9b59649d4fbe427e4f486b8bad6