Rules - Sometimes less is more

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.