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

Procedural Intentional Non-Compliance (PiNC) (rule breaking!) and Your Safety Culture. By Roger Baker, President Safety Focus Group LLC Fairfax, VA. Special Credit and Thanks to David L. Huntzinger PhD, CSP, FRAeS VP Safety & Security TAG Aviation USA. Who me?? I would never do that!.

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

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  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 won’t 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; let’s 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 What’s 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 problem…press on Sometimes the motivations from a peer act to increase incidents of non-compliance.

  20. No Adverse Peer Pressure May be premeditated (“we’re going’…”) May be situational (“this isn’t 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. Findings—The Bottom Line!Non-compliance rarely results in an accident or incident, however:It 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 • “Let’s take a look and see” • “If you can get it inside, it will fly” • “Why check the weather, we’re 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 doesn’t matter here PiNC is the issue, regardless of motivator it’s 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.Don’t 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 don’t 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 NO…Company 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 can’t stop people from being human….so let’s 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

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