Failure to Follow Written Procedures

Drury, Colin G.; Drury Barnes, Catherine; Bryant, Michelle R; Applied Ergonomics Group, Inc.; Civil Aerospace Medical Institute

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Failure to Follow Written Procedures

2017-12-01
By Drury, Colin G. ; Drury Barnes, Catherine ; Bryant, Michelle R

[PDF-1.36 MB]

English

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Details:

Creators:

Drury, Colin G. ; Drury Barnes, Catherine ; Bryant, Michelle R

Drury, Colin G. ; Drury Barnes, Catherine ; Bryant, Michelle R Less -
Corporate Creators:

Applied Ergonomics Group, Inc. ; Civil Aerospace Medical Institute

Applied Ergonomics Group, Inc. ; Civil Aerospace Medical Institute Less -
Corporate Contributors:

United States. Office of Aerospace Medicine
Subject/TRT Terms:

[+]

Air Transportation Crashes Aviation Law Aviation Maintenance Aviation Safety Failure To Follow Procedures Human Error Human Factors Human Factors In Crashes Procedures Vehicle 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
Collection(s):

FAA Civil Aerospace Medical Institute US Transportation Collection
Main Document Checksum:

[+]

urn:sha256:f440c479da53e2ed8909b67c7d283c22ef76f9b59649d4fbe427e4f486b8bad6
Download URL:

https://rosap.ntl.bts.gov/view/dot/35515/dot_35515_DS1.pdf
File Type:

No Additional Files

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Failure to Follow Written Procedures

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