I take full responsibility. Safety Champ helps technicians understand how AEI culture affects safety and procedural discipline in everyday maintenance work.
Failure to Follow Procedures (FFP) remains one of the leading safety issues in maintenance. It is not just a technical problem; it is about attitude, commitment, and how teams work under operational pressure.
Instead of a "blame and train" response, we need a systematic approach that addresses organizational contributors and strengthens safety culture, documentation quality, and reporting behavior.
Open full introduction
I take full responsibility
This project is designed to help you, our technicians, better understand and appreciate how AEI's culture impacts safety with respect to failure to follow procedure by focusing on the culture of procedure following.
Occurrence reports have shown in recent years that many maintenance safety incidents arise precisely due to failure to follow procedures, agreed procedures when performing individual tasks, known as Failure to Follow Procedures (FFP). While most technicians are fully aware of the consequences of failing to follow procedures – and have likely received training on this issue – FFP continues to be one of the leading safety issues in aviation maintenance.
FFP is not a technical issue - it is about attitude and commitment.
This requirement is simple, but its implementation is not. Despite ongoing education and a focus on compliance, FFP is one of the most prevalent human factors problems in aviation maintenance and contributes to the majority of all accidents/incidents.
The historical response to FFP has been to focus on the employee, leading to a cycle of blame through training or disciplinary action. While blame and training may be quicker and easier in the short term, experts have found that person-centred mitigation measures such as “blame and train” are not effective in reducing FFP.
Currently, instead, a systematic approach is needed that addresses contributors at all levels of the organization.
All of you, our technicians have the technical knowledge to safely perform your jobs, so why does failure to follow procedure (FFP) remain a leading cause in administrative actions? Reducing FFP events and improving an organization's safety culture require continuous effort and a shared commitment. All of us must work together and be able to prompt one another to follow procedures at all times.
We must all understand that when it comes to FFP, I take full responsibility.
Why was AEI inspired to create the Safety Champion project?
Why was AEI inspired by the idea of creating a Safety Champion project based on the FAA training course aimed at “creating champions for rules-following”?
Let's take a closer look:
According to an FAA Office of Aerospace Medicine report, FFP is associated with up to 87% of maintenance-related safety events. FFP refers to situations in which an individual, either intentionally or unintentionally, does not adhere strictly to written procedures or organizational policies.
The FAA emphasizes that while the requirement to follow procedures “as written” appears straightforward, practical implementation is far more complex due to human factors influences.
FFP is rarely purely an individual issue; rather, it is often influenced by systemic and organizational factors such as:
- workplace culture
- production pressure
- fatigue
- training quality
- communication
Therefore, effective mitigation requires a comprehensive organizational approach focused on:
- safety culture
- fatigue management
- improved documentation
- fostering an open reporting
Read more in the full article:
Werfelman, L., 2022. Failure to Follow. Aviation Safety World. Flight Safety Foundation, 16 March. Available at: https://flightsafety.org/asw-article/failure-to-follow
Maintenance Errors – A Reality in Aviation
Overall, maintenance errors can appear to be a small problem. Boeing’s analysis has long put maintenance:
- as a primary cause of just 3 - 4% of hull-loss accidents
- and a contributing cause of about 10%
By comparison, flight crew actions are cited as a primary cause in more than 60%. In 2020’s accidents, IATA said, maintenance was a threat in 21%. It defines a threat as an event or error that occurs outside the pilots’ influence but requires their attention and management to maintain safety margins.
Researchers talk of:
Errors of omission (such as failing to install O-ring seals on turbine engine chip detectors)
Errors of commission (such as using incorrect fasteners to install a cockpit windshield).
Timing errors (performing a task at the wrong time or in the wrong order).
Precision errors (such as using the wrong setting on a torque wrench).
Perception errors (“I didn’t see that”) and slips (“I didn’t mean to do that”)
Wrong assumptions (“I assumed we returned to Stand 513, where the aircraft’s integrated drive generator oil levels had to be checked, but we went to Stand 517”)
Technical misunderstanding (“I tried to replace the landing gear hydraulic-retract actuator, but I didn’t understand what I had to do”).
“There is no silver bullet for any of this.” “It’s all about awareness.”
“Dirty Dozen” – The 12 Human Factors
Each of you knows or at least has heard of “Dirty Dozen” list of 12 human factors that can degrade your ability to perform effectively and safely and lead to maintenance errors.
“Father of the Dirty Dozen” – Who Is Gordon Dupont?
Gordon worked for Transport Canada from March 1993 to August 1999 as a Special Programs Coordinator. In this position he was responsible for coordinating with the aviation industry in the development of programs which would serve to reduce maintenance error. In this position he assisted in the development of Human Performance in Maintenance (HPIM) Part 1 and 2. The "Dirty Dozen" maintenance Safety posters were an outcome of HPIM Pt 1.
Prior to working for Transport, Gordon worked for seven years as a Technical Investigator for the Canadian Aviation Safety Board later to become the Canadian Transportation Safety Board. In this position he saw firsthand the tragic results of maintenance and human error.
He has been an Aircraft Maintenance Engineer and Commercial pilot in Canada, United States and Australia. He is the past president and founding member of the Pacific Aircraft Maintenance Engineers Association.
One of the most common maintenance errors involves a mechanic forgetting to do a task planned for completion before a job is closed out (such as removing an engine thrust-reverser lockout pin after investigating an engine bleed-air issue).
G. Dupont classifies violations in three main ways:
- Situational violation - mechanic concludes a job can’t be completed without violating a procedure. This is often related to time pressures. It may not be repeated. The situation seems to justify the violation.
- Exceptional violation - occurs when there appears to be no other way to accomplish the task.
Example: a manual calling for three people to be used at all times when moving an aircraft. If a mechanic is out sick, crewmates may decide to push the aircraft carefully using the only two people available.
- Routine violation - happens when a mechanic believes there is a better way to complete a task and sees no negative consequences to the ad hoc procedure. It may start as a situational violation, but over time the informal procedure may become a norm.
Drury, C. G., Drury Barnes, C. & Bryant, M. R., 2021. Confronting the Challenge of Failing to Follow Procedures.
Aviation Maintenance Magazine, 21 Nov. Available at: https://avm-mag.com/confronting-the-challenge-of-failing-to-follow-procedures/
