Aircrews, Rules and the Bogeyman: Mapping the Benefits and Fears of Noncompliance
1.1. Conflicting Paradigms
1.2. Population of Interest
- Do the interviewees recognise a difference between the way work is done and the way work is prescribed in their own work experience?
- Is a difference between work-as-done and work-as-prescribed considered undesirable?
- Why is the difference between the way work is done and prescribed not solved?
- Can the current set of rules and procedures match the dynamic complexity of flight operations?
- Can you give an example of a difference between the way work is done and prescribed?
- Is a 100% compliance attainable considering the goals that need to be attained?
- Are operators allowed to adapt rules to a situation they encounter?
- Why are operators reluctant to use their discretionary space?
- How can rules and procedures be aligned with the dynamic complexity of flight operations?
- When fire fighter capacity is low, airport regulations state that large passenger-carrying helicopters are not allowed to take off or land at the airbase. In this case, the helicopters land and pick up passengers at a suitable spot outside the airbase, where airport regulations do not apply.
- Due to budget cuts one airbase is active only three days a week. The area is often used for training purposes. If a pilot needs a precautionary landing on one of this airbase’s inactive days, airport regulations state that the helicopter will not be able to take off after repairs are finished. A precautionary landing outside this airbase does not meet these restrictions, hence taking off is allowed.
- Out on a training exercise a helicopter needed repairs. Since it was not stationed at home base, the equipment needed to comply with the regulations for “working at heights” was not, and could not be made, available. The crew chose not to comply and did the repairs without being secured. This resulted in an operational helicopter and a successful training exercise.
2.2. Document Study
- Self-shooting: on 21 January 2019, an F-16, the follow-on aircraft in a formation of two, conducted a shooting session over the Vliehors. During the flight, the F-16 fired its on-board gun at a practice target .
- Dangerous goods: on 24 February 2016, officers from the Military Hazardous Substances Control Corps found an oxygen cylinder violation regarding its testing, labelling and release for road transport. The investigation committee made six recommendations. During a debate in the House of Representatives, a request was made to the government to commission an independent investigation into the implementation of the recommendations .
- Risks identified: from 17 to 19 June 2019, 14 students were on professional practice training at Woensdrecht Air Base and the nearby Ossendrecht military training ground. At 08.29 a.m. Wednesday morning, while preparing the assignment for the day, the group was unexpectedly caught in a thunderstorm. Some students were struck by lightning and one of them was seriously injured .
- Weak signals: the Defence Safety Inspectorate announced a study at the end of 2019 to gain insight into the handling of minor incidents at Defence and thereby strengthen the learning capability of the organisation. The research focuses on the function of signalling of minor incidents and the influencing factors .
- NH-90 helicopter crash: on Sunday 19 July 2020, an NH-90 maritime helicopter with a four-man crew practised both approaches and deck landings on the patrol ship Zr. Ms Groningen. During the execution of a deck landing circuit, the helicopter hit the water. The two crew members in the cockpit did not survive the accident .
2.3. Data Analysis
3. Findings and Interpretations
3.1. Importance of Compliance
I think rules are very important. They exist for a reason. We say rules are written in blood.(Interviewee 4)
A difference between an official regulation that says you’re not allowed to fly when drunk on alcohol, for instance, and the way work is done is unacceptable.(Interviewee 1)
We have these rule books with important rules, and if I break them, I will personally be held accountable, legally accountable.(Interviewee 2)
So, I’m allowed to put the helicopter down on the other side of the airport fence, which is potentially far more dangerous because it’s an uncontrolled area. […] But inside the airport fence, which is controlled terrain, we have rules that don’t let [us put the helicopter down without sufficient firefighters].(Interviewee 3)
If you return to base early because of a technical problem, you’re not allowed to land. I’d have to deviate to an alternate [landing spot] until the fire department has finished monitoring the refuelling of other helicopters. […] But the airfield is right there!(Interviewee 2)
When it comes to compliance, it’s about hard law, the bottom line. It doesn’t mean you can’t deviate, but [the deviation] has to be written down.(Interviewee 7)
When he was talking to air traffic control he declared an emergency but didn’t make a PAN or mayday call and he didn’t select the SSR 7700 code as prescribed by regulation.(document case study 1)
Amidst perceived continuing pressure to validate her existence, the RNLAF is adapts her processes to the circumstances so that she can do with less.(document case study 5)
Why are things difficult? Because we live in the Netherlands, with crowded air space and politicians who will not accept that every now and then we’ll drop an aircraft on a school playground.(Interviewee 12)
The certificate means that the organisation is compliant with rules and so has assured safety to a certain extent.(Interviewee 11)
No, we just put a person in [a] position because his career needs a post as commanding officer. Yes, of course, he’s incredibly good at counting stuff, but he doesn’t know [much] about military aviation regulations.(Interviewee 11)
3.2. Need for Adaptation in Work
My brain is like an iceberg that holds lots of penguins. And with each new rule a new penguin appears. At some point the iceberg is full, no room for more penguin-rules. And as I get older, the iceberg starts to melt. In other words, with new rules, penguins fall off the iceberg. I’m just hoping it will be a penguin-rule about an area I need to avoid, because my map will show that too [to remind me], and not a the penguin-rule about the emergency procedure in case of an engine fire.(Interviewee 2)
I don’t think we should have a rule for everything. We just need a general set of rules that we can use to make the right decisions in situations we haven’t [dealt with] before. But, take a look at our operations manual. […] As a pilot you can’t know [all] these rules by heart. It’s just too many, with 50 exceptions for every rule in the book.(Interviewee 5)
The world is changing much faster than rules of any kind can follow. We cannot even think that fast.(Interviewee 6)
Every day we feel the tension between trying to fully comply with the rules and doing our job.(Interviewee 5)
These are examples that no one thought of when writing the rules.(Interviewee 8)
We have standard operating procedures, but if before a flight you decide to do things differently, that’s fine, as long as you let your colleagues know.(Interviewee 7)
Policy makers at Central Staff who produce new rules and agreements with politicians stand too far away from the work actually done. They get so wrapped up in their own policy world and political climate that they have no idea what is needed at the operator level.(Interviewee 10)
I have a perfectly functioning aircraft out in the field after a precautionary landing which turned out to be a false alarm. Now I can’t get the aircraft off the ground because there’s a rule on it somewhere, that [even if] it’s safe to go […] And that hampers task execution, because now the aircraft stays in the field unsheltered from weather, and maintenance and security [crew] need to [get to it] there. It just hampers us.(Interviewee 3)
If we have to attend a forest fire [somewhere], I hope the rules will let us. That we won’t have to ask [if] we are allowed to do this outside airbase opening hours […] or will we just put out the fire?(Interviewee 3)
Mission first. We must have air power, that’s the first priority […]. We’re in a military world, which we sometimes forget.(Interviewee 11)
The drive that people have to get it done, it’s part of our DNA and undeniably has a lot of good in it […] but sometime a little dark edge to it.(Interviewee 9)
We [they] are more ‘can-do’ than we dare realise. Of course, we [they] do ‘plan-do-check-act’, but we [they] also do ‘can-do-react’. It takes us[them] a long way, but it can also make us [them] fall flat on our face. […] We [they] don’t solve the problem, we [they] just try to figure out how we [they] can proceed as planned.(Interviewee 12)
It’s even about simple things, like driving regulations. Every truck driver is obliged to take a 30-min break every three hours of driving. But when we [they] are on exercise in another country and need to move equipment, we [they] pay our drivers an exercise fee [..] so the rules don’t apply to military drivers.(Interviewee 10)
Not everything legal is smart to do. Not everything allowed is the sensible thing to do. I can get my neighbour pregnant, no law that prohibits that, but it’s not smart. It’ll give [me] so much trouble.(Interviewee 12)
That’s part of the rule base we, like every other ministry, have to comply with. […] There is no way to sugar-coat that.(Interviewee 9)
The other day I was in a working group […] to see what is possible. Immediately someone said that it will be impossible to change the airbase into a stage field, like the Americans have.(Interviewee 1)
I don’t know if we have a procedure for adapting or changing rules. I hope so, but I’m not sure. I should know, but I don’t.(Interviewee 8)
[It takes great force] to try to change the most important things, and that’s nearly impossible.(Interviewee 5)
We continuously need to assess our rule base with a plan-do-check-act loop. Are the rules still valid?(Interviewee 4)
3.3. Enduring Tension
Being compliant does not necessarily mean being safe. […] The airport rules do not apply to areas outside airports, but then situation becomes less safe because you move from a bit of fire fighter capacity to none at all.(Interviewee 4)
We have an exercise planned which requires me to have an emergency radio. So, I call the responsible department to ask for one. But I won’t get this radio because it was not requested on the right form, even though they have them in stock. After filling out the proper form I do get the radio, but it hasn’t been prepared. I have to load the settings myself, even though that’s the job of the support department. The paperwork is more important than the operational tasks I have to do.(Interviewee 2)
When they get to that number, landing is no longer allowed. This rule is intended to minimise the sound burden for these areas as much as possible. However, the surroundings of these helicopter landing spots fall outside the extent of this rule. That means that helicopters are still allowed to land within as little as a couple of metres of a landing spot, because this falls under the rules of field landings. Obviously, this workaround makes it hard to meet the intent of minimising the sound burden.(Interviewee 10)
[When discussing complex situations with commanding officers] I have no idea why they don’t. It’s probably human behaviour, [them thinking] I’ve resolved the situation in the easiest way for myself, so why choose the hard way?(Interviewee 8)
If a rule hampers job execution, then together with rule makers/enforcers you try to find an alternative means of compliance that lets us continue our operation, or [find] a way to deviate from the rules. But the answer can never be ‘No that’s impossible and that’s the end of it’. Not changing a rule is a joint decision, with the operator involved.(Interviewee 6)
Operators don’t cross safety lines […]. You won’t risk your life on a simple training flight.(Interviewee 3)
If they make a decision and can explain it afterwards […] they will be supported.(Interviewee 9)
I am allowed to deviate if it means enhancing the safety of the flight. But I have to prove that safety was enhanced. But that is rather impossible, since I can’t prove what would have happened had I not deviated. However, I have to explain in writing why I deviated from my flight authorisation. If [the explanation] is not accepted I have to go up one level and explain it to the next commanding officer.(Interviewee 2)
Undeniably, every now and then, including deployments, one has to land aircraft in unregulated places. […] We need to train [pilots] and give them the discretionary space to become and stay smart operators.(Interviewee 10)
I had this situation where pilots would fly back to the airbase when something was wrong with the aircraft, instead of making a precautionary landing as prescribed in the checklists. So, I addressed this situation and what I saw next was pilots always making a precautionary landing, even when flying back was the more sensible and practical course of action. In other words, they stopped thinking for themselves and simply followed what they saw was an order.(Interviewee 4)
It shows up the just culture, so to speak […] and it does harm, especially when [distrust] is directed at the employees involved. Personally, I think Central Staff and the Inspectorate seem to have an urge to jump at the chance to […] press charges, whatever. That doesn’t help.(Interviewee 12)
Every CO has a CO who also has a CO. Sometimes your CO simply demands you punish someone [after noncompliance], regardless of what you think the best response might be. Especially when something gets picked up by the media or politicians. Then the highest level of our organisation, the secretary and minister of defence exert pressure to respond retributively and this flows through the organisation down to our level.(Supervisor 1 in )
Upper management uses what we call a long screwdriver to turn every CO in the hierarchy to the same position, so to speak. This is how they micromanage a situation deep in the capillaries of our organisation. It’s a lack of trust and a refusal to let things go and be dealt with at the appropriate level(Supervisor 7 in ).
His CO said to him: ‘Okay, listen. Remember that incident last year? When the Commission of Inquiry comes, just bend over and take one for the team.’(Focus group 1 in )
That’s one of the biggest issues in this organisation, the underlying problem, the lack of trust. Trusting the operator to make a decision. This professional knows best. Trust another, [trust] everything we do.(Interviewee 3)
6. Limitations and Strengths
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
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Boskeljon-Horst, L.; Boer, R.J.D.; Steinmetz, V.; Dekker, S.W.A. Aircrews, Rules and the Bogeyman: Mapping the Benefits and Fears of Noncompliance. Safety 2023, 9, 15. https://doi.org/10.3390/safety9010015
Boskeljon-Horst L, Boer RJD, Steinmetz V, Dekker SWA. Aircrews, Rules and the Bogeyman: Mapping the Benefits and Fears of Noncompliance. Safety. 2023; 9(1):15. https://doi.org/10.3390/safety9010015Chicago/Turabian Style
Boskeljon-Horst, Leonie, Robert J. De Boer, Vincent Steinmetz, and Sidney W. A. Dekker. 2023. "Aircrews, Rules and the Bogeyman: Mapping the Benefits and Fears of Noncompliance" Safety 9, no. 1: 15. https://doi.org/10.3390/safety9010015