I do not recall how Boeing classified the non-compliance events. However,
it seems that if the procedural non-compliance is rooted in a lack of
individual / crew ability it will fall into one of the 3 following bins:
1. A lack of procedural knowledge? (testable)
2. A lack of procedural skill? (testable)
3. An inability to recognize the conditions requiring the procedure?
(partially testable with today's methods)
*** If the non-compliance was wilful it's a whole different problem. The
most important question in the non-compliance is wilful is:
1. Do peers correct the non-compliance?
If so, the intervention should focus on the one individual or crew that
wilfully deviated from procedure.....
If not, the intervention should focus on the organization philosophies,
policies, and practices that directly and indirectly support this
non-compliance.
If the non-compliance can be isolated to individual ability, there are two
important components of an individual's ability: Recognition & Response.
We cannot respond to something we do not recognize.
I believe that the next generation of LOS design will include a systematic
approach that will engineer error producing conditions into the scenarios.
The next generation of LOS design will challenge and test the crew's
ability to both "Recognize and Respond" to a spectrum of conditions that
trigger the need for CRM and/or Procedural skills. Our triggers are often
isolated to the blatantly obvious like a fire light. Fire lights are easy
to recognize and have a clear and well practiced procedural response.
These are important but do not challenge the crew to recognize some of the
more subtile conditions that lead to error or non-compliance. A recent
study by Capt. Robert Sumwalt highlights that crews handle major failures
much better than the subtile or indiscript situations.
The next generation of LOS development will require developers to use a
list of conditions like they would an ISD task list. The condition list
will become an essential component for building scenarios. Indoctrination
training syllabai will expose pilots to all the major condition groups.
Annual scenarios will rotate through these condition groups to insure the
pilots visit them regularly.
Does anyone know if any LOS developers are systematically using a condition
list for building scenarios? I know of a few that use weather, field, and
aircraft condition parameters but none that use error producing or
difficult to recognize conditions. I would be interested in other opinions
about what developers and managers can do or have done to address the
procedural non-compliance challenge.
Best Regards,
Vince Mancuso