The central issue in many mishaps is “procedural intentional noncompliance,” or PINC. Yes, it is true that we all make mistakes now and then; we violate procedures unintentionally. But flying a high performance aircraft in a dynamic environment isn’t easy and we have safeguards built in via cockpit automation, crew resource management, and redundant procedures. These procedures are designed to protect us. When we intentionally violate procedures these safeguards break down. When we do this habitually, it is only a matter of time before it all catches up with us.
There is a hybrid case of PINC that seems to result when you have an entire organization where the people in charge have gotten too sure of themselves and haven't had any real oversight. What then? Here is an example: Letters.
Everything here is from the references shown below, with a few comments in an alternate color.
[Huntzinger] What’s interesting is that PINC events typically involve crews who have been flying most of their adult lives — veteran aviators who train on simulators once or twice a year; attend initial and then recurrent training classes that cover procedures, FARs, limitations and other best practices; practice CRM; ride with check airmen; and so on. In short, they clearly know the rules and regulations, yet they intentionally violate them.
Aviators who have reached the top – the senior airline captain or the business aviation chief pilot – are at the highest risk. They know their jobs and are in positions where there is very little push back from above or below.
[Huntzinger] From research and practical experience, we have found that there are three elements to a PINC event. First, there is some sort of reward for the violator; second, it follows a situational assessment, which covers, at the very least, the associated risks; and third, the action is unlikely to produce any adverse reaction from peers. You have to have all three elements in place to go PINC. If any one of them is missing or incomplete, the whole process shuts down.
[Huntzinger] One of the major motivators is economic, whether it is for the person or the company served. A good example occurred a few years ago, when La Guardia Airport was hammered by a heavy, wet snowstorm. The plows and ground de-icing equipment were keeping pace and the airport was open, but most crews canceled their flights because the snowfall was so heavy they could not get from the deicing pit to the runway with a safe margin. Most crews. However, two flights departed, both from the same airline. Do you know why? That particular airline paid by the flight. That is, the pilots were not on salary, but paid by each leg completed. No fly, no pay.
“No fly, no pay” applies to a lot of airline crews who are paid by the hour unless they have provisions for trip guarantees. (They are paid even if the trip cancels.) When the crew’s paycheck depends on flying, the motivation to violate a procedure is high.
[Huntzinger] Another reward is internally driven and has to do with a sense of duty, the it-is-my-job-and-I’ll-get-it-done syndrome. Pride is a motivator as well. It’s closely associated to duty, but not quite the same thing. Pride involves being known as the go-to guy, the one everyone counts on to get the job done. Lots of people take pride in their abilities and rightly so. Many of us are very competent at a challenging, complex profession and we like it when people recognize that fact.
When pilots have a personal relationship with passengers, there is additional pressure to ensure our positive reputations do not suffer by failing to accomplish an assigned task.
[Huntzinger] The personal lives of the crew are often motivators as well. How many of us have missed a soccer game or an anniversary? How many of us have been threatened with making the next one or else?
Here again, having a personal relationship with passengers multiplies the number of cases of get-home-itis that might adversely affect a pilot’s decisions.
[Huntzinger] Once a motivator has been established, there has to be some feeling that by ignoring the rules, the outcome will likely be successful. This assessment involves several considerations, or questions: Can I handle this? Do I have the skills, experience or the hardware to even do this? Can I get away with this?
The threat of being caught increases with larger organizations because there are more “witnesses” without a personal stake in the successful outcome of the procedural noncompliance. It follows, then, that the threat of being caught is decreased in small flight departments, especially those flying from small airfields.
[Huntzinger] The last PINC element involves fellow pilots, colleagues, passengers or superiors — one’s peers. A person blows off the rules only when confident that no one in the peer group will react negatively. The absence of negative reaction could result from their not knowing, from knowing and not caring, or actually endorsing the behavior. Regardless, if no one is likely to criticize or complain, think PINC.
When the top pilot is infected with PINC, the disease metastasizes, that is it spreads like a cancer. Any chief pilot needs to worry that not only does his or her actions place the flight operation at risk, these same actions telegraph the message to everyone else that PINC is tolerated.
[Huntzinger] I have discovered that while not all PINC events end in disaster, many disasters begin with PINC episodes. That probably results from the fact that people tend to underestimate the situation and overestimate their abilities. Research back in the 1980s, Boeing did a study of 232 accidents. One of its researchers’ findings was that the pilot flying (PF) failed to follow procedures in about half of the events and that the pilot monitoring (PM) failed to follow procedures in about 20 percent of the accidents. These actions combined with some other nonstandard situations involving weather, ATC, maintenance and such to cause the accident. The crews were aware of some of the nonstandard situations while they happened, but were unaware of others. The average number of contributing factors was four and the highest was 20.
[Huntzinger] So to prevent PINC from occurring, consider ways to counter the economic motivation, be that to benefit the individual or the individual’s company. One mitigation scheme is to put crews on salary rather than paying them by the leg. If the pilot knows that they will be paid, regardless of whether the flight is completed or not, one temptation to avert the rules is removed.
Similarly, companies should build some flexibility into schedules to accommodate delays and into their cost structures to cover the costs associated with delays and thereby ease the pilots’ worries and their inclination to push on when they should not.
Having a Plan B for alternate transportation or hotel accommodations pre-arranged or considered can help alleviate the inconvenience of an aborted trip or diversion. Any additional incurred costs should be considered to be an insurance policy.
To eliminate PINC, it’s important to eliminate passengers from the formula. Create procedures that prevent passengers from interfering with the conduct of the flight. They can plead, rant and rave but the approach criteria, for example, are cast in concrete. If they continue to interfere, have them removed from the area and banned from flying with you in the future. This can all be preempted by having a proactive program that clearly explains to passengers their roles, responsibilities and the limits of their authority.
It helps to have senior leadership buy-in. If the CEO has a “don’t interfere with the pilots” philosophy you obviously bypass many of these problems. But how do you gain this level of trust from your company’s top leaders? You can do this by frequently (and accurately) framing all decisions in terms of safety. A “flow control” delay, for example, can be better explained to be a problem of “too many airplanes and too little airspace due to hazardous weather.” If the senior leadership knows safety is a top concern on days where the trip does get from Point A to Point B, they will be more receptive when the trip ends up at Point C or never leaves in the first place.
[Huntzinger] To counter a wrongheaded sense of “duty,” examine the operations culture and its ops procedures.
This is a leadership problem. We need to stop celebrating hacking the mission under impossible odds and apologizing for delays, cancellations, and diverts. In fact, we should flip those. When a crew finds itself as the only aircraft to make it off the ground during a heavy fog, we need to ensure no corners were cut. If a crew abandons an approach well before the missed approach point and ends up at the alternate, we need to celebrate their timely and safe decision-making.
Beyond that, there must be clear disincentives for risk-taking and PINC episodes. These could include fines, demotions, suspensions or even termination. Many companies make procedures compliance a condition of continued employment. One less drastic but powerful consequence is to make the perpetrator go out and teach people about compliance. For many pilots, speaking in public is a fate worse than death.
A word of caution here. If you uncover a PINC episode, do not jump to conclusions. Investigate and then act. There may have been a good reason why the person did PINC. There may have been an emergency. It could be that the rule is old and overcome by events and needs rework. Maybe it was an unwritten rule or the rule was inappropriate for the conditions. Be sure to understand why. And there may have been a bad reason why there was PINC. Maybe management coerced them and things turned out bad, so a scapegoat was needed. They could have been pressured by peers, a passenger or something else. Find out what it was and fix it.
A good safety program can defuse many of these problems as the anonymous reporting system gives people the opportunity to speak up, ahead of time. You will have to look for the underlying factors, just as they were described above. Always ask: Why?
The best way to prevent Procedural Intentional Noncompliance in ourselves is also the best way to prevent it in others; we should set a good “by the book” example and brag about it. By becoming vocal advocates for procedural compliance we place a personal stake in the game. If we were then to break with this philosophy, not only are we violating a procedure, we are going back on our publicly proclaimed ethics. When we hear or witness procedural intentional noncompliance, we need to speak up.
Are normal procedures as outlined in the AFM mandatory by the FARs in a part 91 operation? Even if the OEM is not really keeping the AFM up to date since the aircraft is an older model, or the OEM has arguably overlooked something?
[The reader provided specifical examples which have been redacted for privacy reasons.)
Signed, R. Fader
Fort Lee, New Jersey
Our team offers you the following penned by Larry, a very astute legal-minded professional aviator. I trust his judgment implicitly but I would like to add something up front.
I flew for a number of outfits in the Air Force that were allowed to operate as they saw fit and they often courted disaster while relying on luck to keep them safe. Sometimes that worked, sometimes it didn’t. I flew a version of the Boeing 707 (EC-135J) that relied on the manual of another variant (EC-135C) that came from a third (C-135B). All of this more than a decade after the aircraft were out of production. We ended up with a lot of undocumented systems and procedures and we flew the airplane the way the most experienced pilot in the squadron was taught. Every now and then a pilot would return and wondered why we were doing something against procedure and we figured out somebody along the way corrupted the process. That squadron crashed an airplane a few years after I left.
I don’t think we as pilots are good at improvisation. If you are making it up as you are flying, chances are you are going to make a mistake or overlook something that could make your life safer and easier. I encourage you to write these informal procedures into a form that makes them look like they came from the manufacturer and see if everyone involved is onboard with doing it the same way. Once you have buy in, I would run an all-hands accident investigation. The premise is to suppose the airplane in question crashed with a loss of all hands and took out some ground personnel too. (When I did this in the Air Force, I would say the airplane crashed into the base elementary school.) Now examine those procedures and hypothesize how well they would stand up to NTSB and public scrutiny.
Larry will draw the legal definitions for you, but he also points out that just because something is legal it may not be safe or prudent. I would like to add to that by saying the stakes are too high for “good enough” to be good enough. That’s my two cents. Larry’s follows.
Thank you for your questions. You ask: “In general, are normal procedures as outlined in the POH/AFM mandatory by the FARs in a part 91 operation?” In my opinion, the short answer is no, adherence to the NORMAL procedures in the POH/AFM is not mandatory under the FARs for operations conducted under FAR Part 91. You then cite several examples of procedures contrary to the NORMAL procedures listed in the FAA-approved POH/AFM and ask if I would consider them as intentional non-compliance.
First, with respect to the POH/AFM being current and onboard the airplane, refer to 14 CFR §91.9 (b)(1) below:
§91.9 Civil aircraft flight manual, marking, and placard requirements.
(a) Except as provided in paragraph (d) of this section, no person may operate a civil aircraft without complying with the operating limitations specified in the approved Airplane or Rotorcraft Flight Manual, markings, and placards, or as otherwise prescribed by the certificating authority of the country of registry.
(b) No person may operate a U.S.-registered civil aircraft—
(1) For which an Airplane or Rotorcraft Flight Manual is required by §21.5 of this chapter unless there is available in the aircraft a current, approved Airplane or Rotorcraft Flight Manual or the manual provided for in §121.141(b); and
From the information you provided, it appears there is an FAA-approved, OEM provided POH/AFM onboard the airplane or airplanes you reference in your questions. (Note: The POH/AFM lists the serial number of the airplane to which it is assigned. If a manual does not indicate a specific aircraft registration and serial number, it is limited to general study purposes only.) If so, this complies with §91.9 (b) (1), provided the POH/AFM is current. However, you also state the “OEM is not really keeping the AFM up to date since the aircraft is an older model.” If the airplane’s OEM is no longer in business, and no other entity is responsible for the airplane model, then it is my opinion that the latest, most current manual commercially available specific to the airplane’s serial number would be meet the intent of the regulation. However, if the airplane’s operator is intentionally choosing not to purchase an available subscription update service or a more current manual from the OEM or other approved entity, and there is a more current POH/AFM available, then in my opinion the POH/AFM onboard would not meet the intent of §91.9 (b) (1).
(Note: 14 CFR Part 91 places primary responsibility on the owner or operator for maintaining an aircraft in an airworthy condition. The owner/operator of the airplane is responsible for its airworthiness, which in this case means ensuring a current, approved manual is onboard the airplane. However, §91.9 (b) (1) states that no person may operate the airplane unless there is available in the aircraft a current, approved Airplane or Rotorcraft Flight Manual. This places the responsibility on the person (or certificated pilot) operating the airplane to make sure the current manual is onboard.)
Expanding on your question: “In general, are normal procedures as outlined in the POH/AFM mandatory by the FARs in a part 91 operation?” Refer to §91.9 (a):
“Except as provided in paragraph (d) of this section, no person may operate a civil aircraft without complying with the operating limitations specified in the approved Airplane or Rotorcraft Flight Manual, markings, and placards, or as otherwise prescribed by the certificating authority of the country of registry.
The regulations only require the operator (person or certificated pilot) to comply with the operating limitations of the airplane which are specified in the LIMITATIONS section of the POH/AFM or by markings and placards. This includes the airplane’s weight and balance limitations.
PINC, or procedural intentional non-compliance has traditionally meant willfully, intentionally, and deliberately operating contrary to standard operating procedures (SOPs), airframe manufacturer’s guidance, FAA guidance (e.g., AIM, Advisory Circulars, Handbooks, etc.) or FAA regulations. In the examples you cite above, although the operations appear legal at first blush, they are arguably contrary to published manufacturer’s guidance, SOPs, and accepted safety standards. In my opinion, they are classic examples of PINC or perhaps normalization of deviance.
In my experience, operations such as you describe go unchecked until FAA gets involved after an accident or incident. A noteworthy example is when FAA rescinded exemptions to the Collings Foundation after their deadly B-17 accident at Bradley (KBDL), 2 Oct 2019.
It is only then that such operations are looked at as to whether they are careless or reckless. Willful, deliberate, and intentional non-compliance with published guidance is not only foolhardy; it may be reckless. The NTSB has determined that “reckless” operation results from a deliberate or willful disregard of the regulations or accepted standards of safety so as to potentially or actually endanger the life or property of another. The examples you cite could potentially be reckless under 14 CFR §91.13 Careless or reckless operation, especially if such operations resulted in an accident or incident.
Furthermore, those who purposefully disregard published guidance, especially from the aircraft manufacturer, bear the burden of presenting a legally compelling alternative explanation for their deviations sufficient to overcome the inference of carelessness in the event of an FAA investigation. Otherwise, a finding of carelessness should be expected. And, although you did not mention the level of certificate you or others hold, keep in mind that NTSB has long held that an airline transport pilot must exercise those privileges with the highest degree of care and judgement.
In summary, although certain operations may be legal, they may not be safe or prudent. FAA maintains a webpage where such safety concerns may be submitted. (https://hotline.faa.gov/) Submission may be made by name or anonymously. I have used this avenue in the past with timely, effective results. The FAA inspector phoned and we spoke, the offending pilot was counseled by the inspector, and my identity was never revealed to the pilot.
I hope this information has been helpful and responsive to your questions.
Huntzinger, David, Ph.D., “In the PINC,” Business & Commercial Aviation, January 2006
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