The temptation to compare ourselves to others and use someone else’s behavior as an excuse doesn’t end with childhood. We have likely all been guilty of asking the question, “Why do I have to? Nobody else is doing it that way.”
We are all too willing to blame our actions (or inactions) on the culture of our organization … our management … overly restrictive regulations … and the list could go on.
Organizational norms are powerful, but the bottom line is: Change begins with me!
In the aviation industry, inadequate technical documentation or failure to follow procedures accounts for a large number of safety violations. To truly fix the problem, the culture must be changed.
A “culture of noncompliance” contributes to issues in technical documentation and following procedures. Although a number of efforts should be taken to change such a culture, two interventions should be made priorities:
- First, initiate an industry mandate requiring users to address known documentation issues – at all levels of the organization.
- Second, expand incident investigations to identify details associated with documentation issues.
Changing a culture requires a collective effort at all levels of the organization and typically begins with senior leadership commitment. Change, however, does not end with senior leadership. As aviation professionals, each of us has a responsibility to lead change through our own actions.
Address Known Issues
Requests from users for manual revisions are often lumped with other company requests and not addressed in a timely manner. Even when addressed quickly, the users may not be informed.
When users do not see timely results from manual revision requests, they frequently give up and create “workarounds” to complete tasks, ignoring deficiencies in the manuals until a problem occurs. The operators and manufacturers must make a renewed commitment to expedite the process to address issues with documentation.
- Revisit (with airlines, in particular) the process for timeliness of document revision.
- Hold manufacturers, airlines, maintenance organizations and individuals responsible for inferior documents that they knowingly create and/or continue to use.
- Report bad documentation when you see it. Request that it be addressed. Actively change the culture!
Expand Incident Investigations
Guidelines for incident/accident investigations must require a complete root cause analysis (RCA) when it appears a procedure was not followed.
The cause may be an error, where a well-documented procedure was not properly executed. Or the cause may be a document-related issue where the instruction was not clear, complete or correct.
Although sufficient for an investigation, the categories are too broad from the standpoint of actionable change to mitigate future risk. Also, existing reporting systems may contain information relevant to an investigation, but that does not explicitly state what the precursor was to the error.
As an industry, we must focus on improving outcomes of formal and informal investigations of errors and document-related issues by improving the data quality and developing analysis tools. We must determine what the “right” questions are for a reporting system during a formal investigation.
- Change current event and accident investigation forms to have a section dedicated to the use of technical documentation. If technical documentation is suspect, then ensure sufficient root cause analyses.
- Create internal procedures for immediate correction of technical documentation any time it may be a small (or large) contributing factor to a safety event.
- Create procedures and training to help event investigators recognize the manner in which technical documentation may have been a contributing factor to an event.
- Ensure that all FAA accident investigations that identify procedures or documentation as contributing factors also ensure that a proper root cause analysis is conducted.
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