How To Change A ‘Culture Of Non-Compliance’

Oct. 29, 2012
This kind of change requires personal action and a commitment to safety.

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 account for a large number of safety violations. To truly fix the problem, the culture must be changed. We must take responsibility for our actions, demonstrate a high-level of professionalism and work together to reduce or eliminate technical documentation issues as a safety risk.

There are many organizational norms regarding documentation use. A norm that gives tacit approval to ignore technical publications for some maintenance tasks will have negative consequences. This type of norm, perhaps due to the perception that it saves time tends to spread to an increasing number of tasks until an incident occurs or additional maintenance costs are realized.

Like a bad habit, organizational norms can present many challenges to changing cultures, processes and tools. As aviation professionals, we have the power to break this habit.

A panel of aviation industry and government officials, including OEMs, airlines and third-party developers, met earlier this year and identified the following five challenges surrounding technical documentation:

  • Consistent technical documentation. (See “How To Play By The Same Rules,” June/July 2012, Ground Support Worldwide.)
  • Accurate content for users. See “Give Me The Right Instructions – Please!” September 2012, Ground Support Worldwide.)
  • Industry culture and professionalism.
  • Business case for documentation improvement.
  • Industry standards.

As for the third challenge, panel members identified a “culture of non-compliance” that contributes to issues in technical documentation and following procedures.
Although a number of efforts should be taken to develop a culture of safety and compliance, panel members identified two interventions they would like to see 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 Identified 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 “work arounds” 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 and consider a minimum time limit that any documentation issue remains open.
Industry Actions

  • Revisit (with airlines, in particular) the process for timeliness of document revision.

Government Actions

  • Hold manufacturers, airlines, maintenance organizations and individuals responsible for inferior documents that they knowingly create and/or continue to use.

Individual Actions

  • 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. As well, existing reporting systems (mentioned in the September issue), 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.
Industry Actions

  • 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.

Government Actions

  • 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.

Individual Actions

  • Report all detailed information about documentation issues that contributed to an error/event/accident.
  • Use voluntary reporting to describe when and why a job card or procedure was not used properly or at all.

To summarize, there are a number of ways to change a culture. There are many programs that can be implemented and processes changed. The panel suggested two actionable methods to change the non-compliance culture and address the hazards associated with failure to follow procedures and technical documentation.

Programs and leadership commitment are necessary, but not enough. Change requires personal action and a commitment to safety. Programs and processes are only successful if followed.

Are you ready to change the culture in your organization? It begins with you, the aviation professional.

Dr. Katrina Avers is a Research Scientist at the Federal Aviation Administration in the Civil Aerospace Medical Institute Human Factors Research Lab. Dr. Avers takes a practical, science-based approach and has worked to develop applied solutions that can be used across the industry.