Standard Operating Procedures - Why follow them?

[CD]

Here is an article from a while ago that some might find interesting...

Standard Operating Procedures - Why follow them?

IN AUGUST 1987, a North West Airlines MD 80 attempted to depart Detroit Wayne County airport and crashed shortly after leaving the runway. The wing flaps and slats had not been set as is required for the aircraft to takeoff and begin to fly.

The taxi checklist, which included latching the auto throttles and setting flaps and slats, was interrupted by ground traffic control. A misunderstanding on the part of the cockpit crew resulted in the aircraft taxiing down the wrong taxiway. Ground traffic control corrected the problem but the taxi checklist was never resumed. A small child was the only survivor.

In May 1979 an American Airlines DC-10 on a flight leaving Chicago crashed on take-off when the number one engine broke away from the wing. The aircraft rolled and crashed killing all 271 passengers and two people on the ground.

What was the cause? An in-house procedure was developed by Maintenance to remove and re-install the engine and pylon (the structure which holds the engine onto the wing) as a unit, using a forklift rather than removing each separately, as specified by the manufacturer. This simplified procedure saved the company 200 hours of work and was deemed safer because it involved fewer connections to hydraulic, fuel and electrical lines. In this case, the pylon attachment points were overstressed and some attach pins were damaged during installation. As a result, the pylon attachments broke and the engine assembly fell off as the aircraft left the runway.

When ValueJet flight 592 crashed into the Florida everglades in May 1996, it was carrying a shipment of out-of-date oxygen generators which discharged and sparked an inferno in the forward baggage compartment of the fated DC-9. The fire quickly burned through the flight cables plunging the aircraft out of control into the swamp. No one survived.

The oxygen generators, had not been disarmed or contained safely for shipment. ValueJet was not authorized to carry hazardous materials (HAZMAT). The oxygen generators are HAZMAT, but were labled COMAT (Company Materials) and tagged as empty by a shipping clerk before being loaded onto the aircraft.

In each of these tragic accidents, a key contributing factor was a failure to follow Standard Operating Procedures (SOPs) - taxi check, aircraft manufacturer maintenance procedures, and appropriate dangerous goods shipping procedures.

Why would highly trained professionals not follow procedures designed to ensure optimum safety? An oversight or lapse of attention; acceptance of non-standard practices; the desire for quicker, easier procedures.

Human behaviorists tell us the motivation to follow SOPs is weak while the motivation not to follow the SOPs is strong. As human beings, we do those actions which reward us with results that are reliable, positive and immediate. If an action does not give a tangible or quick result, there is little reinforcement for it.

For example, not following a SOP might give you more time for coffee or visiting or doing something more pleasant. The negative consequences of deviating from an SOP are not always apparent or immediate. So why should I follow the SOPs when the tendency of human behavior discourages me from doing so?

Each of us has to answer this question for ourselves. I can think of several very good reasons.

1. There are professional standards and behavior which I subscribe to and take pride in because I am proud to call myself a professional.

2. The SOPs have been written in blood. Many of the procedures were developed because someone was injured or died doing it another way.

3. It is what I am paid to do. I fly the aircraft or fix the aircraft or manage the passengers the way the Company wants me to. I am not paid to create my own procedures.

4. When the pressure is on, I tend to make decisions based on habits I have developed. If the habits are SOPs, chances are the decision will result in the desired outcome. This is much less likely if I follow a procedure developed on my own.

5. I am legally bound to perform according to the SOPs. An argument in a court of law or at a coroner's inquest that "I thought I had a better way" just won't hold up.

6. SOPs provide a consistent and stable guide for behavior through a wide range of conditions.

7. Following SOPs offers the best insurance for safety.

~ by Dennis Froese, YYC Maintenance

[xsbank]

Good one, CD.

[trey kule]

Yes excellent post.

If I may add a comment, it is management's job to see that SOP's are being followed, something that seems to be lacking in many operations.

[200hr Wonder]

This should go on the front of every SOP book as a good reminder of why the remainder of the book was written!

[BigBlindVSSmallBlind]

Hate to be that guy but it's our job as pilot's to ensure that the SOP's are adhered to. It's management's job to make sure that there's proper training and an open professional atmosphere in order for us to excel at what we think we do best.

[twinpratts]

Anytime you deviate, just make sure you have a good reason.

I always picture myself before the board of inquiry, and ask myself 'tell us again, Mr. twinpratts why you elected to ....?' before i make a call like that.

[NO LINK*]

A very interesting article--please read.

http://www.flightsafety.org/asw/feb07/a ... p35-38.pdf

[dutch-roller]

nice link NO LINK*. regardless of how conscious i am of complacency, it's always there, creeping back in. once a week i like to read something like this. reminds me of my responsibilities, keeps me in check. so thanks, CD too.

[CP]

Oh gosh oh golly. Im just getting this warm fuzzy feeling at all this happiness and comaraderie being spewed. Cant somebody please disagree?

[C-FABH]

Those the same SOPs which call for landing + nav lights in daytime and IFR clearance about 15 minutes before taxi?