Procedural Intentional Procedural Intentional Non-Compliance (PiNC)Non-Compliance (PiNC)

(rule breaking!)(rule breaking!)and and

Your Safety CultureYour Safety CultureByBy

Roger Baker, PresidentRoger Baker, PresidentSafety Focus Group LLCSafety Focus Group LLC

Fairfax, VAFairfax, VA

Special Credit and Thanks toSpecial Credit and Thanks to

David L. HuntzingerDavid L. HuntzingerPhD, CSP, FRAeSPhD, CSP, FRAeS

VP Safety & SecurityVP Safety & SecurityTAG Aviation USATAG Aviation USA

Who me?? Who me?? I would never do that!I would never do that!

Rules are for Rookies, Right!Rules are for Rookies, Right!

I am a seasoned veteran, I know the I am a seasoned veteran, I know the rules necessary to keep me safe!rules necessary to keep me safe!

What we will cover today.What we will cover today. What is it?What is it? Why does it happen?Why does it happen? How prevalent is this?How prevalent is this? What happens when we do it?What happens when we do it? How to prevent itHow to prevent it

PNC – What Is It?PNC – What Is It?Not following procedures:Not following procedures: FARs, OEM FARs, OEM

standards, Company policies, SOPsstandards, Company policies, SOPs

Two Types:Two Types:1. Sometimes unintentional1. Sometimes unintentional (PuNC)(PuNC)

mistakes, inattention, distraction, confusionmistakes, inattention, distraction, confusion(Co-Pilot on Co freq, misses altitude callout)(Co-Pilot on Co freq, misses altitude callout)

not talking about these events todaynot talking about these events today

2. Intentional2. Intentional Non Compliance (PiNC) Non Compliance (PiNC)

Procedural Intentional Non-Procedural Intentional Non-Compliance (PiNC)Compliance (PiNC)

Crew knows the rules;Crew knows the rules;flying most of adult lifeflying most of adult lifeinitial, recurrent traininginitial, recurrent trainingsimulators every six monthssimulators every six monthsstandardization rides with check airmanstandardization rides with check airmanno mysteries hereno mysteries here

However, However, We bWe break the rules anyway!reak the rules anyway!

Some assumptions!Some assumptions! Known procedures produce known Known procedures produce known

outcomes.outcomes. Most, if not all, rules and regulations Most, if not all, rules and regulations

were written in blood.were written in blood. Standards should guarantee Standards should guarantee

repeatable results.repeatable results. Bad rules produce bad results.Bad rules produce bad results. There are mechanisms for changing There are mechanisms for changing

bad rules.bad rules.

Research Shows…….Research Shows…….

Once you start deviating from Once you start deviating from the rules, you are almost the rules, you are almost twicetwice as likely to commit an error with as likely to commit an error with

serious consequences!serious consequences!NTSB ReportsNTSB Reports

PiNCPiNCExampleExample

Charter – Passengers and cargoCharter – Passengers and cargoFlying up channel, terrain on both sidesFlying up channel, terrain on both sidesLowering ceilings, narrowing channelLowering ceilings, narrowing channelBridge ahead, with deck in cloudBridge ahead, with deck in cloud““Hopelessly committed”Hopelessly committed”Pulled into overcast, let down on other Pulled into overcast, let down on other

sideside

PiNCPiNC

Example – continuedExample – continuedPilot said:Pilot said:

Paid by the flightPaid by the flightImportant cargo to destinationImportant cargo to destinationWanted to get the job doneWanted to get the job doneKnew channel continued on other sideKnew channel continued on other sideNo one would know any differentNo one would know any different

Three factors in Procedural Three factors in Procedural Intentional Non Compliance Intentional Non Compliance

(PiNC)(PiNC)1.1. Motivation (Reward)Motivation (Reward)

1.1. High Probability of SuccessHigh Probability of Success

2.2. Absence of Peer Pressure or Absence of Peer Pressure or ReactionReaction

All three required, or PiNC does not All three required, or PiNC does not occur.occur.

1. Motivation (Reward)1. Motivation (Reward) Can-do attitude (duty calls?)Can-do attitude (duty calls?) Company PressureCompany Pressure Peer PressurePeer Pressure Economic (self or company)Economic (self or company) Learn/experiment (new situation)Learn/experiment (new situation) Self Pressure (Get-home-it is)Self Pressure (Get-home-it is) Client/customer PressureClient/customer Pressure

Motivation SolutionMotivation Solution

With the exception of self pressure or With the exception of self pressure or self economic pressure, the company self economic pressure, the company must eliminate the motivations with must eliminate the motivations with a positive company safety culture.a positive company safety culture.

Do the right thing, for the right Do the right thing, for the right reasons, at the right time, EVERY reasons, at the right time, EVERY TIME!TIME!

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

Supervisors know who will and who won’t Supervisors know who will and who won’t bend or break the rules.bend or break the rules.

The rule breakers are often rewarded for the The rule breakers are often rewarded for the mission accomplishment!mission accomplishment!

Employees receive praise for over-Employees receive praise for over-accomplishments or at least no accomplishments or at least no admonishment.admonishment.

Reward system is upside down; let’s reward Reward system is upside down; let’s reward the completely normal, positive the completely normal, positive performance.performance.

Create Create disdisincentives for PiNCincentives for PiNC

Fines, demotions, suspensionsFines, demotions, suspensions

Terminations are not uncommonTerminations are not uncommon

The compliance culture must be The compliance culture must be reinforced; reinforced;

Follow the rules, or else!Follow the rules, or else!

2. High Probability of Success2. High Probability of Success Under-estimate the gravity of the Under-estimate the gravity of the

situation. (This is not bad, is it?)situation. (This is not bad, is it?)

Over-estimate your abilities. (I am Over-estimate your abilities. (I am superman, after all!)superman, after all!)

Past experience (I have done this Past experience (I have done this before with no bad experience!)before with no bad experience!)

High probability of successHigh probability of success

Basic situational assessmentBasic situational assessmentCan I deal with this?Can I deal with this?My skills, hardware, weatherMy skills, hardware, weatherWhat’s the worst that could happen?What’s the worst that could happen? Nothing, damage aircraft, fatality, Nothing, damage aircraft, fatality, Get caughtGet caught

Probability of Success Solutions?Probability of Success Solutions?The employee has to find the solution to this The employee has to find the solution to this

problem within themselves.problem within themselves.

Reinforced bad behavior breeds continued Reinforced bad behavior breeds continued bad behavior.bad behavior.

Rationalization of the gravity of the situation Rationalization of the gravity of the situation seems to lessen the risk in our minds, but seems to lessen the risk in our minds, but not in reality.not in reality.

Habitual departures from the rules are often Habitual departures from the rules are often ignored by management-turn the other ignored by management-turn the other cheek.cheek.

Does complacency play a role in this issue? Does complacency play a role in this issue?

3.3. No Adverse Peer PressureNo Adverse Peer PressureAnother crewmember or a passengerAnother crewmember or a passenger

CRM seems to have a positive effect, CRM seems to have a positive effect, however it falls short in a single pilot however it falls short in a single pilot operation.operation.

No comment? No problem…press onNo comment? No problem…press on

Sometimes the motivations from a Sometimes the motivations from a peer act to increase incidents of non-peer act to increase incidents of non-compliance.compliance.

No Adverse Peer PressureNo Adverse Peer Pressure

May be premeditatedMay be premeditated (“we’re going’…”)(“we’re going’…”)May be situationalMay be situational (“this isn’t so (“this isn’t so

bad…”)bad…”)May wait to see if anything changesMay wait to see if anything changesDecision making often occurs rapidlyDecision making often occurs rapidlyVery seldom an opportunity to bail outVery seldom an opportunity to bail out““Hopelessly committed”Hopelessly committed”However--However--Outcome depends on luck, Outcome depends on luck,

circumstancescircumstances

PiNC OutcomesPiNC Outcomes

Sometimes successfulSometimes successfulSome others have done this - no Some others have done this - no

problemproblemI have never had an accidentI have never had an accident

Some succeed, but get caughtSome succeed, but get caught

Sometimes, not successfulSometimes, not successful

Findings—The Bottom Line!Findings—The Bottom Line!

Non-compliance rarely results in an Non-compliance rarely results in an accident or incident, however:accident or incident, however:

It always results in a greater risk for the It always results in a greater risk for the operation!operation!

Many disasters begin with a Many disasters begin with a PiNC episode.PiNC episode.

You have read the accident You have read the accident reports!reports!

VFR into IMCVFR into IMC Equipment malfunction, but deferredEquipment malfunction, but deferred ““Let’s take a look and see”Let’s take a look and see” ““If you can get it inside, it will fly”If you can get it inside, it will fly” ““Why check the weather, we’re going Why check the weather, we’re going

anyway!”anyway!” ““Although the weather was Although the weather was

deteriorating, the Captain pressed deteriorating, the Captain pressed on.”on.”

FrequencyFrequency

So, how often does this happen?So, how often does this happen?No real good empirical dataNo real good empirical data““Hangar flying” says more of it than we thinkHangar flying” says more of it than we think

(or want, or can tolerate)(or want, or can tolerate)Consider past year (especially 4Q04, 1Q05) in Consider past year (especially 4Q04, 1Q05) in

both the corporate and EMS worlds?both the corporate and EMS worlds?

ObservationsObservations

““Bad” companiesBad” companiesculture breedsculture breeds PiNC PiNCencourage or even demand PiNCencourage or even demand PiNC

““Good” companiesGood” companiesself self – want to do more than they should – want to do more than they should dutyduty – feel they are doing the right thing– feel they are doing the right thing

Observation (continued)Observation (continued)

Good or bad company doesn’t matter hereGood or bad company doesn’t matter herePiNC is the issue, regardless of motivatorPiNC is the issue, regardless of motivator

it’s real and happening out thereit’s real and happening out therepotential for disaster is therepotential for disaster is therecan happen to anyonecan happen to anyone

We have to address it…We have to address it…

Suggestion for the CEO safety Suggestion for the CEO safety message to employees.message to employees.

Don’t Do Me Any Favors!!Don’t Do Me Any Favors!!Just follow the rules.Just follow the rules.

CAUTION !!!CAUTION !!!

PiNC should not be automatic “Stop Rule”PiNC should not be automatic “Stop Rule”Always ask: “Why?”Always ask: “Why?”

There may have been a good reason.There may have been a good reason. emergencyemergency unwritten rule (unwritten rule (vs.vs. published) published) outdated policy or proceduresoutdated policy or procedures inappropriate for conditionsinappropriate for conditions

Prevention StrategiesPrevention StrategiesImproving the Improving the Situational AssessmentSituational Assessment aspect aspect

Self AssessmentSelf AssessmentEducate folks – active safety programEducate folks – active safety programYou are not Superman - average guyYou are not Superman - average guyWe don’t want SupermanWe don’t want SupermanUse accident info to show vulnerabilitiesUse accident info to show vulnerabilitiesCreate simulator sessions with PiNC Create simulator sessions with PiNC

eventseventsDemand self disciplineDemand self discipline

Prevention StrategiesPrevention Strategies

Improving the Improving the Situational AssessmentSituational Assessment aspect aspectSituationSituation

Emphasize procedural complianceEmphasize procedural complianceGood FOM/GOM can deal with anythingGood FOM/GOM can deal with anythingwx, performance, unstable approachwx, performance, unstable approacheliminates guessworkeliminates guessworkloss of Situational Awareness?loss of Situational Awareness?mandatory go-aroundmandatory go-aroundJust say NO…Company can defend that!Just say NO…Company can defend that!

Prevention StrategiesPrevention Strategies

Improving the Improving the Situational AssessmentSituational Assessment aspect aspectAccountabilityAccountability

Survive but are caughtSurvive but are caughtCompany, FAA, other pilotCompany, FAA, other pilot

There will be accountability for PiNCThere will be accountability for PiNCIt can be It can be thethe worst thing you do… worst thing you do…

Prevention StrategiesPrevention StrategiesTo DoTo Do

CompanyCompanyClear policies and proceduresClear policies and proceduresStandardization--Remove Standardization--Remove

dilemmasdilemmasDemand good CRM Demand good CRM No incentives for PiNCNo incentives for PiNCClear disincentives for PiClear disincentives for PiNCNCClear incentives for complianceClear incentives for compliance

Prevention StrategiesPrevention Strategies

To DoTo DoCompany (continued)Company (continued)

Investigate all PiNC eventsInvestigate all PiNC eventsAnonymous or notAnonymous or not

Improve the procedures as Improve the procedures as necessarynecessary

Prevention StrategiesPrevention StrategiesTo DoTo Do

Self: Recognize that…Self: Recognize that…Procedures are there for a reasonProcedures are there for a reasonYou (and your aircraft) have You (and your aircraft) have limitationslimitationsThe situation may be worse than you The situation may be worse than you thinkthinkNothing is worth killing yourself forNothing is worth killing yourself forPeople want you home in one piecePeople want you home in one pieceSelf discipline is the keySelf discipline is the key

Prevention StrategiesPrevention Strategies

To DoTo DoThe other guyThe other guy

SPEAK UP!!!SPEAK UP!!!Your peer may be under pressureYour peer may be under pressureHelp relieve that pressureHelp relieve that pressureAcknowledge it, follow SOP, fly safeAcknowledge it, follow SOP, fly safeFail safe to the most conservative Fail safe to the most conservative

optionoptionDeal with the pressures laterDeal with the pressures later

Discussion PointsDiscussion Points

Notice that most of the substantive actions Notice that most of the substantive actions belong to the Companybelong to the Company

The company sets the tone and tenor of The company sets the tone and tenor of operationsoperations

Pilots can only do so much on their ownPilots can only do so much on their ownTry some of these ideas!Try some of these ideas!The more you do, the better it will be!The more you do, the better it will be!

Discussion PointsDiscussion Points

The belief that individual characteristics are the The belief that individual characteristics are the main cause of rule-breaking behavior leads to main cause of rule-breaking behavior leads to searching for remedies in areas such as searching for remedies in areas such as selection, training, and incentives.selection, training, and incentives.

The real causes of PiNC are predominantly in The real causes of PiNC are predominantly in

poor planning, failures to improve procedures poor planning, failures to improve procedures and the existence of opportunities. and the existence of opportunities.

Final Thoughts!Final Thoughts! You can’t stop people from being You can’t stop people from being

human….so let’s build an error human….so let’s build an error tolerant system of checks and tolerant system of checks and balances.balances.

If something goes wrong, you can If something goes wrong, you can count on second guessers who have count on second guessers who have the benefit of hind sight….SOthe benefit of hind sight….SO

Ask Yourself this question….Ask Yourself this question….

Will my decisions and actions be:Will my decisions and actions be:

PrudentPrudent

Reasonable by company standardsReasonable by company standards

Consistent with best practices?Consistent with best practices?

Bias to the conservative!Bias to the conservative!

Break the chain!Break the chain!

Accidents are bad for Accidents are bad for business!business!

FLY SMARTFLY SMART

FLY SAFEFLY SAFE