Increasing reliance on procedural solutions for operational safety

Statistics, showing that procedural deviation is the highest-ranking category in crew- or operator-caused accidents. This is also true in the nuclear industry, and in the maritime industry. However, the aviation industry is moving toward an environment in which airline standard operating procedures are so rigidly enforced that line pilots rarely stray outside their constraints. These pilots are intimidated or bullied by trainers, check pilots for even thinking about deviating. Unfortunately that condition is what they get comfortable with and it’s how they eventually learned to use automation systems. Standard Operating Procedures (SOPs) were originally intended to be guidelines. The result is a very standard use of flight deck and ground automation within the confines of those strict SOPs. The assumption of the adequacy of SOPs in all situations leads to the limiting of not only the understanding of the automation but the degree to which it’s use is managed and/or employed in the right situations. The zealous enforcement of SOPs is seen as a barrier to weakened flying skills, the lack of pilot aviation knowledge, a decreasing level of pilot experience throughout the industry, and the rapidly rising level of automation sophistication and dependence on it.

Management must recognize the danger of over-procedurization, which fails to exploit one of the most valuable assets in the system, the intelligent operator who is “on the scene.” The alert system designer and operations manager recognize that there cannot be a procedure for everything, and the time will come in which the operators of a complex system will face a situation for which there is no written procedure. Procedures, whether executed by humans or machines, have their place, but so does human cognition.

Proceduralization is linked to the general push toward bureaucratization of an ever-growing number of aviation activities.  Certification and flight-standards regulatory agencies progressively extend their fields of intervention along procedural lines, but oftentimes lack the operational knowledge, experience, manpower, and an in-depth understanding of the conditions under which aviation safety has been concretely achieved and socially produced.  Reinforcing proceduralization remains a widely accepted, pro-forma response when safety barriers are perceived to be insufficient.  It is easier to audit and assess deviations from procedures or processes than to understand and assess the social construction of safety on a case-by-operational-case.  Reports and analyses all point toward complex organizational adjustments and unbearable constraints that little by little, push pilots, air traffic controllers, mechanics and other players into uncharted territories for which no standardized procedures are adequate.  A deep understanding of the conditions under which people operate daily (including reporting on their assumptions, beliefs, difficulties, instinctive responses, expertise, successes, and so on) is required that doesn’t depend on paperwork audits.  One of the most recent (and paradoxical) targets of proceduralization is the safety culture itself.*