RULES – SOMETIMES LESS IS MORE Thesis work submitted in partial fulfillment of the requirements for the MSc in Human Factors and System Safety Richard Abbott and Espen de Lange LUND UNIVERSITY SWEDEN Date of submission: 2017-07-08 RULES – SOMETIMES LESS IS MORE Richard Abbott and Espen de Lange Under supervision of Johan Bergström, PhD i ABSTRACT The Aviation industry is ultra-safe. Rules and procedures have been attributed as a contributory factor for attaining this high level of safety. The complexity of the aviation system has risen dramatically in the last few decades due to the development and introduction of modern aircraft and on-board technological innovations. Every day pilots encounter situations they did not expect. During those situations, they make many decisions that result in safe outcomes. But how are the rules integrated into their decision-making process? Do the rules help or hinder them? Do they consider the rules, and if so, how, and why? This thesis explores these questions using qualitative case study methodology to provide a better understanding of how, or even if, rules and procedures help pilots make decisions in difficult and challenging situations. According to the literature, 75% to 80% of aviation accidents are caused by human error. A common reaction to this attribution is the development and publication of new rules and procedures to make sure these “human errors” do not happen again. However, in industries with increasing complexity, such as aviation, unknown, unusual, and unexpected situations may arise at any time. It is not possible for the rule writer to envision every situation that a pilot may encounter. This study reveals when there is a gap between the work as imagined by the rule writer and the work as done by the pilots, pilots must use more than just rules and procedures to make decisions and solve problems – they must rely on their knowledge and experience. This study suggests that organizations would be well-served to invest in the development and implementation of a rule management process that allows them to monitor the gaps that exist between their procedures and the situations the pilots face. This study submits that the pilots must be an integral part of this process. Developing an understanding of the gap could contribute to organizational knowledge which in turn could help the pilots improve their skills at adapting to the challenging and difficult situations they face. ii ACKNOWLEDGMENTS Out of the many people who have contributed to this thesis, we would like to begin by extending our thanks and appreciation to front-line operators in all industries throughout the world. Those of you who work at the sharp end of the spear are in the “line of fire” every day. You are ultimately the ones who must make things work. That is why you can provide so much rich information for researchers to use to explore and develop ideas that make our complex industries safer. We want to thank the sixteen pilots who were willing to dedicate so many hours of their time so we could learn more about how they do their jobs day in and day out. We were famished for the rich information that only you could provide. And you satisfied that hunger. Our curiosity and the questions we asked must have seemed strange at times, but you endured – even seemed to enjoy it. We must give warm thanks to our thesis supervisor, Johan Bergström. Your constant positive encouragement we suspect was not always due to the quality of our work, but surely also to keep us going. You showed an interest and curiosity in our work that made it easier to move forward when we felt stuck. Your ability to keep us on track and stop us from over-complicating the task was invaluable. Your aviation knowledge was also of great help. Keen and special thanks also to Anthony Smoker and Arie Adriaensen who provided relevant suggestions and input whenever we asked. The employer of one of the co-researchers expressed great enthusiasm towards our thesis question. Just knowing that some of our colleagues and company executives look forward to reading our work has been encouraging and has helped us focus on making the thesis as readable as possible. We hope we succeeded. Our wives and children have had to put up with us for over two years while we were doing our coursework and research. You have done well hiding your thesis-fatigue. Your encouragement and patience is not forgotten. Last but not least, a very sincere thanks to all of our classmates. The discussions we had during our assignments were long, sometimes tough, but always respectful and educational. The get togethers at the Bishop Arms in Lund were much the same. Those memories will always be with us. We wish you all the best. iii TABLE OF CONTENTS Contents Abstract………………………………………………………………………… ii Acknowledgements………………………………………………………..….. iii Table of Contents…………………………………………………………..…. iv List of Figures and Tables……………………………..………………………vi 1 Introduction .............................................................................................................................. 1 1.1 Background ............................................................................................................................................. 1 1.2 Research Focus and Objectives ...................................................................................................... 2 2 Literature Review ................................................................................................................... 4 2.1 Introduction ............................................................................................................................................ 4 2.2 Development and Implementation of Rules and Procedures in Aviation................... 4 2.2.1 History ........................................................................................................................................ 4 2.2.2 A shift in thinking about accident causation and preventive actions ............... 6 2.2.3 Have things really changed? .............................................................................................. 9 2.3 Gaps Between Work as Imagined and Work as Done ...................................................... 12 2.3.1 Who makes the rules and for whom do they make them? .................................. 12 2.3.2 Rules as resources for action ........................................................................................... 14 2.3.3 Monitoring and exploring the gap ................................................................................. 16 2.4 Summary and Need for Empirical Research ......................................................................... 19 2.4.1 Review of research objectives fulfilled by literature review.............................. 19 2.4.2 Empirical research needs .................................................................................................. 19 3 Research Methodology ........................................................................................................ 20 3.1 Introduction ......................................................................................................................................... 20 3.2 Research Strategy ............................................................................................................................. 21 3.2.1 Choosing the method .......................................................................................................... 21 3.2.2 Designing the research ....................................................................................................... 21 3.3 Data Collection ................................................................................................................................... 23 3.4 Reliability and Validity ................................................................................................................... 24 3.5 Limitations, Challenges, and Ethical Considerations ....................................................... 26 3.6 Framework for Data Analysis ...................................................................................................... 28 4 Research Findings: Description, Analysis, and Synthesis ..................................... 30 4.1 Introduction ......................................................................................................................................... 30 4.2 Initial findings ..................................................................................................................................... 30 4.2.1 What do rules mean in the respondent’s daily work? (thoughts about rules in general) ............................................................................................................................................... 30 4.2.2 Are rules considered in challenging and difficult situations? If so, how? ..... 32 4.2.3 Initial findings summary ................................................................................................... 37 4.3 Theme development ......................................................................................................................... 38 4.4 Analysis and Synthesis .................................................................................................................... 40 4.4.1 Theme 1: No rules for rapidly changing situations ................................................ 40 4.4.2 Theme 2: Rules and professional identity.................................................................