Procedural Intentional Non-Compliance (PiNC) (rule breaking!) and Your Safety Culture

1
Procedural Intentional Non-Compliance
(PiNC)(rule breaking!)and Your Safety Culture

• By
• Roger Baker, President
• Safety Focus Group LLC
• Fairfax, VA

2
Special Credit and Thanks toDavid L.
HuntzingerPhD, CSP, FRAeSVP Safety
SecurityTAG Aviation USA
3
Who me?? I would never do that!

• Rules are for Rookies, Right!
• I am a seasoned veteran, I know the rules
  necessary to keep me safe!

4
What we will cover today.

• What is it?
• Why does it happen?
• How prevalent is this?
• What happens when we do it?
• How to prevent it

5
PNC What Is It?

• Not following procedures FARs, OEM standards,
  Company policies, SOPs
• Two Types
• 1. Sometimes unintentional (PuNC)
• mistakes, inattention, distraction, confusion
• (Co-Pilot on Co freq, misses altitude callout)
• not talking about these events today
• 2. Intentional Non Compliance (PiNC)

6
Procedural Intentional Non-Compliance (PiNC)

• Crew knows the rules
• flying most of adult life
• initial, recurrent training
• simulators every six months
• standardization rides with check airman
• no mysteries here
• However, We break the rules anyway!

7
Some assumptions!

• Known procedures produce known outcomes.
• Most, if not all, rules and regulations were
  written in blood.
• Standards should guarantee repeatable results.
• Bad rules produce bad results.
• There are mechanisms for changing bad rules.

8
Research Shows.Once you start deviating from
the rules, you are almost twice as likely to
commit an error with serious consequences!NTSB
Reports
9
PiNC

• Example
• Charter Passengers and cargo
• Flying up channel, terrain on both sides
• Lowering ceilings, narrowing channel
• Bridge ahead, with deck in cloud
• Hopelessly committed
• Pulled into overcast, let down on other side

10
PiNC

• Example continued
• Pilot said
• Paid by the flight
• Important cargo to destination
• Wanted to get the job done
• Knew channel continued on other side
• No one would know any different

11
Three factors in Procedural Intentional Non
Compliance (PiNC)

• Motivation (Reward)
• High Probability of Success
• Absence of Peer Pressure or Reaction
• All three required, or PiNC does not occur.

12
1. Motivation (Reward)

• Can-do attitude (duty calls?)
• Company Pressure
• Peer Pressure
• Economic (self or company)
• Learn/experiment (new situation)
• Self Pressure (Get-home-it is)
• Client/customer Pressure

13
Motivation Solution

• With the exception of self pressure or self
  economic pressure, the company must eliminate the
  motivations with a positive company safety
  culture.
• Do the right thing, for the right reasons, at the
  right time, EVERY TIME!

14
Are we giving awards and praise to the wrong
people?

• Supervisors know who will and who wont bend or
  break the rules.
• The rule breakers are often rewarded for the
  mission accomplishment!
• Employees receive praise for over-accomplishments
  or at least no admonishment.
• Reward system is upside down lets reward the
  completely normal, positive performance.

15
Create disincentives for PiNC

• Fines, demotions, suspensions
• Terminations are not uncommon
• The compliance culture must be
• reinforced
• Follow the rules, or else!

16
2. High Probability of Success

• Under-estimate the gravity of the situation.
  (This is not bad, is it?)
• Over-estimate your abilities. (I am superman,
  after all!)
• Past experience (I have done this before with no
  bad experience!)

17
High probability of success

• Basic situational assessment
• Can I deal with this?
• My skills, hardware, weather
• Whats the worst that could happen?
• Nothing, damage aircraft, fatality,
• Get caught

18
Probability of Success Solutions?

• The employee has to find the solution to this
  problem within themselves.
• Reinforced bad behavior breeds continued bad
  behavior.
• Rationalization of the gravity of the situation
  seems to lessen the risk in our minds, but not in
  reality.
• Habitual departures from the rules are often
  ignored by management-turn the other cheek.
• Does complacency play a role in this issue?

19
No Adverse Peer PressureAnother crewmember or a
passenger

• CRM seems to have a positive effect, however it
  falls short in a single pilot operation.
• No comment? No problempress on
• Sometimes the motivations from a peer act to
  increase incidents of non-compliance.

20

• No Adverse Peer Pressure
• May be premeditated (were going)
• May be situational (this isnt so bad)
• May wait to see if anything changes
• Decision making often occurs rapidly
• Very seldom an opportunity to bail out
• Hopelessly committed
• However--Outcome depends on luck, circumstances

21
PiNC Outcomes

• Sometimes successful
• Some others have done this - no problem
• I have never had an accident
• Some succeed, but get caught
• Sometimes, not successful

22
FindingsThe Bottom Line!Non-compliance rarely
results in an accident or incident, howeverIt
always results in a greater risk for the
operation!Many disasters begin with a PiNC
episode.
23
You have read the accident reports!

• VFR into IMC
• Equipment malfunction, but deferred
• Lets take a look and see
• If you can get it inside, it will fly
• Why check the weather, were going anyway!
• Although the weather was deteriorating, the
  Captain pressed on.

24
Frequency

• So, how often does this happen?
• No real good empirical data
• Hangar flying says more of it than we think
• (or want, or can tolerate)
• Consider past year (especially 4Q04, 1Q05) in
  both the corporate and EMS worlds?

25
Observations

• Bad companies
• culture breeds PiNC
• encourage or even demand PiNC
• Good companies
• self want to do more than they should
• duty feel they are doing the right thing

26
Observation (continued)

• Good or bad company doesnt matter here
• PiNC is the issue, regardless of motivator
• its real and happening out there
• potential for disaster is there
• can happen to anyone
• We have to address it

27
Suggestion for the CEO safety message to
employees.Dont Do Me Any Favors!!Just follow
the rules.
28
CAUTION !!!

• PiNC should not be automatic Stop Rule
• Always ask Why?
• There may have been a good reason.
• emergency
• unwritten rule (vs. published)
• outdated policy or procedures
• inappropriate for conditions

29
Prevention Strategies

• Improving the Situational Assessment aspect
• Self Assessment
• Educate folks active safety program
• You are not Superman - average guy
• We dont want Superman
• Use accident info to show vulnerabilities
• Create simulator sessions with PiNC events
• Demand self discipline

30
Prevention Strategies

• Improving the Situational Assessment aspect
• Situation
• Emphasize procedural compliance
• Good FOM/GOM can deal with anything
• wx, performance, unstable approach
• eliminates guesswork
• loss of Situational Awareness?
• mandatory go-around
• Just say NOCompany can defend that!

31
Prevention Strategies

• Improving the Situational Assessment aspect
• Accountability
• Survive but are caught
• Company, FAA, other pilot
• There will be accountability for PiNC
• It can be the worst thing you do

32
Prevention Strategies

• To Do
• Company
• Clear policies and procedures
• Standardization--Remove dilemmas
• Demand good CRM
• No incentives for PiNC Clear disincentives
  for PiNC
• Clear incentives for compliance

33
Prevention Strategies

• To Do
• Company (continued)
• Investigate all PiNC events
• Anonymous or not
• Improve the procedures as necessary

34
Prevention Strategies

• To Do
• Self Recognize that
• Procedures are there for a reason
• You (and your aircraft) have limitations
• The situation may be worse than you think
• Nothing is worth killing yourself for
• People want you home in one piece
• Self discipline is the key

35
Prevention Strategies

• To Do
• The other guy
• SPEAK UP!!!
• Your peer may be under pressure
• Help relieve that pressure
• Acknowledge it, follow SOP, fly safe
• Fail safe to the most conservative option
• Deal with the pressures later

36
Discussion Points

• Notice that most of the substantive actions
  belong to the Company
• The company sets the tone and tenor of operations
• Pilots can only do so much on their own
• Try some of these ideas!
• The more you do, the better it will be!

37
Discussion Points

• The belief that individual characteristics are
  the main cause of rule-breaking behavior leads to
  searching for remedies in areas such as
  selection, training, and incentives.
• The real causes of PiNC are predominantly in poor
  planning, failures to improve procedures and the
  existence of opportunities.

38
Final Thoughts!

• You cant stop people from being human.so lets
  build an error tolerant system of checks and
  balances.
• If something goes wrong, you can count on second
  guessers who have the benefit of hind sight.SO

39
Ask Yourself this question.

• Will my decisions and actions be
• Prudent
• Reasonable by company standards
• Consistent with best practices?
• Bias to the conservative!

40

• Break the chain!
• Accidents are bad for business!

41

• FLY SMART
• FLY SAFE