02 Apr 2020 15:50


I was at my hotel bedroom in a neat city outside my hometown, when I was reading this statement by the former FAA’s Associate Administrator for Aviation Safety, Margaret Gilligan in 2015: “in the past, our philosophy was 100% compliance equals 100% safe but we were having accidents. We needed more than regulations. Today, we’re proactive and identify and address risk to prevent accidents. Our success in addressing risk and improving safety in aviation over the past two decades is the result of strong safety partnerships between government and industry to pursue safety improvement collaboratively and in a proactive manner.”

The heat in the cockpit made me feel like pretty much close to a snake in the little lakes of the forest in my country. I was behind this aviation maintenance expert for an engine run up. My boss brought me here to buy a new aircraft for his company, so he was on the ground watching the engine performance outcomes during the run up, and I was assigned to be in the cockpit to monitor the compliance with the proper procedures. No briefing, not a word, but just a cool guy.

I was looking in my mind for everything I did and learned about an engine run up, including training, qualification and experience. So I was really excited about this. As we were walking very confident to the cockpit without saying a word on the relevant procedure, I was hoping a miracle was about to happen, or just the procedures were followed. What do you think? My excitement turned into dreams not coming true, when I saw from the observer’s seat the following happened:

a)        No references followed;

b)        No one rated seated in the right cockpit seat; and

c)         No communication with ATC.

Though all of these above, the Engine Start is about to be executed. That was when I asked this guy: Are you going to start the engines without following any references whatsoever, without anyone qualified at the right seat and without interacting with ATC? His answer was prompt and straight: Damn right, Sergio. Let me call the ATC!

As you may assume in this case, defenses in this safety system did not work. Why do holes appear in James Reason’s Model of Accident Causation? We’ve been taught holes are the result of errors and procedure violations. Against these, we set controls to reinforce the defenses the system possesses. It has to be said most systems and publications I found are human error-related, but what about violations?

I found Dr. Patrick Hudson’s “Bending the Rules: Managing the Violation in the Workplace” publication that says ‘violations are dangerous because violators always assume everyone else is keeping strictly to procedures’. Mental note: What if not?

What should be then the analysis of violations? Let’s share with you a table that compares violations against consequences from Robert L. Helmreich’s “On Error Management: Lessons from Aviation”. We can understand here the hazard violations imply. Types of error operational personnel commit are:

Type of Error

Consequences to Safety in Percentage

Proficiency: 5%


Operational Decision: 6%


Communications: 7%


Procedures: 29%


Violations: 52%


What do these figures mean? They mean something insidious and imperceptible. Operational personnel make a lot of mistakes (52%), but as Helmreich’s survey depicts violations just result in 2% of consequences, which explains that everyone is still making such violations, because “nothing” happens to the system. That is, standards may not be complied with, since the system is laid out in such a manner (defenses, controls and monitoring) that someone else is adhered to the standards to keep it safe!