Have you heard the one about the Dutch pilot, British air traffic controller, Austrian aircraft designer, Welsh procedures writer, and American regulator in a room? Well, it is neither a joke nor a funny story. It is a working group of the European Union Aviation Safety Agency (EASA). The team above is part of the EASA Human Factors (HF) Collaborative Analysis Group (CAG). The work, completed in June, is exemplary of the continuing effort of industry-government to cooperate on safety management. Another version of this story is reported in the 2019 3rd Quarter FAA Maintenance Human Factors Newsletter.
The EASA HFCAG is one of many sources of information to define the European Plan for Aviation Safety (EPAS). The EASA website for the EPAS emphasizes that a key goal of the Safety Management plan is to manage risk. That includes identifying and prioritizing hazards and establishing mitigation plans. Committees like the HFCAG help offer content-specific advice and recommendations. The HFCAG, with about 40 active delegates, is comprised of industry, academic and government human factors specialists. The group includes highly-experienced designers, engineers, pilots, scientists, maintenance organizations, labor organizations and others. Most delegates are from European Union (EU) countries, but that is not a requirement. FAA usually has two representatives, usually personnel from the Chief Scientific/Technical Advisory program.
For the current EPAS planning period, the Human Factors CAG prioritized four areas on which to provide specific assessment and guidance (shown below). Each of these target areas had a small group dedicated to assessing the risks and recommending potential mitigation solutions.
Target Areas for Assessment and Advice:
- Design and Use of Procedures
- Organizational and Individual Resilience
- Senior Management competence and commitment
- Training effectiveness and competence
The remainder of this article describes the recommendation from Target Area 1, the Design and Use of Procedures. Now, we return to the first sentence of this article that seemed to be the starting line of a joke. The multi-disciplinary team included a pilot, air traffic controller, procedure writer, flight deck designer, and a maintenance regulator. Dr. Bill knows this story well because he was the regulatory participant and quasi-lead of the group. From the very start of deliberations, it became clear that the challenges related to design and use of procedures had no country, cultural, or occupational dependence. We all had the same issues.
“….it became clear that the challenges related to design and use of procedures had no country, cultural, or occupational dependence. We all had the same issues.”
At the start of deliberations, the group identified 12 challenges with draft solution paths. Our first written draft and briefing to the entire HFCAG, it was clear that it was necessary to delimit the number of challenges. Upon deliberation, we narrowed and prioritized the recommendations to four categories as shown below.
Safety Challenges Related to Design and Use of Procedures:
- Unclear, Incomplete, etc. Procedures/Instructions
- Inadequate Safety Culture and Root Cause Analysis Regarding Procedures
- Situations where there is no specific procedures for the situation
- Not Applying Proven Technology to Deliver Procedures
For each of the safety challenges, the group characterized a challenge to include: descriptions, example manifestations of the challenge, research approaches, and practical examples and references likely to address the challenges. For each challenge, we offered action-oriented solution paths for EASA action. The group classified all recommendations into one or more categories, including rule-making, safety promotion, or research. In all cases, the recommendations were a combination of Safety Promotion and/or Research. The committee did not recommend new or changed regulations.
Recommendations for Challenge 1: Review and Recommend Methods of Design and Management of Procedures
The committee recommended that EASA commissions a working group to develop generic, multi-domain guidance on the process of design, validation, implementation, and maintenance of effective procedures for publication as safety promotion material. Although cavalier, someone commented that, “If Ikea can create usable assembly instructions for furniture assembly, perhaps our industry could improve procedural guidance.”
Recommendation for Challenge 2: Address Safety Culture and Root Cause Analysis related to Design and Use of Procedures
The committee recommended that EASA place the topic of use of procedures high on the priority list for continuing applied research. Procedural noncompliance is a leading threat to safety, thus it should be an applied research priority. Workers know that R&D should examine the organizational and cultural issues that impact procedural compliance. Results should be published to deliver practical instructions. The reports should be aimed at understanding and addressing organizational culture regarding on-going procedural non-compliance. FAA embarked on this kind of work with the followprocedures.com training, during 2017-19, as reported in AMT, Nov-Dec 2018. That training promotes the importance of a safety culture where everyone associated with the maintenance organization takes personal responsibility for following all procedures, all of the time.
EASA should create root cause analysis (RCA) support that is specifically focused on procedural non-compliance. The research deliverables should help users to ask more and better questions related to procedural non-compliance. The RCA research results should make it easier for industry safety practitioners to effectively identify causes of procedural non-compliance and rapidly implement solutions.
Recommendation for Challenge 3: Design and Deliver Training for Resilient Behavior when Procedures Do Not Match Situations
There cannot be a specific procedure for every action in a complex system. The group recommended that government and industry focus on increasing human and systemic resilience. This means that training regarding human performance variabilities in complex operational conditions must go beyond procedural compliance. Programs must prepare the human to “cope” and to adapt when procedures do not offer solutions/actions match to a situation.
The committee recommended that EASA facilitates the production of training material to effectively inform audiences that procedure following does not automatically equate to safety. Safety emerges from systematic interactions (people, artefacts, training, etc.) and consequently increased focus should be aimed at adaptation skills and defensive operating techniques, ultimately fostering individual and team resilience.
Recommendation for Challenge 4: Design Guidelines and Use of Electronic Checklists (ECL) for Maintenance Tasks
ECLs for maintenance personnel lack structured human factors design approach and often contradict well established design philosophies of the flight deck, e.g. the use of color.
The committee recommended that EASA investigates how properly designed ECL for maintenance personnel could help to provide the same benefits as ECL for flight crews, and as a consequence, reduce human error of maintenance personnel. The committee recommended that EASA creates human factors design considerations for ECL for maintenance personnel which are consistent with established design guidelines for ECL for flight crews.
Conclusions
The small multi-disciplinary team felt that the list of recommendations was short, yet comprehensive. In summary, write excellent procedures, foster an industry culture to use the procedures, seek to understand why a procedure was not used, deliver the procedure using an appropriate methods and technology and train the human to cope when a procedure is not available or relevant.
The recommendations described herein are but one small example of the advice that industry/government panels can offer to all National Aviation Authorities. US Industry/FAA examples include committees like the Commercial Aviation Safety Team (CAST) and the General Aviation Joint Steering Committee (GAJSC). Internal committees like the FAA AVS Human Factors Coordinating Committee (AVS HFCC) is comprised of Human Factors personnel in Flight Standards and Aircraft Certification.
Advisory groups are extremely valuable to help governments manage safety. Multidisciplinary groups offer a broad perspective that can provide the best thinking of government, industry, and academia. Such groups can provide understandable and actionable advice. It is an ideal cooperative situation. Readers should look for opportunities to offer their experience and advice through such advisory participation.
