Once again....
Oh how I love these discussions!
First step: Develop proper SOPs. This is easily said, but very difficult to
accomplish. (There was a point in my career when I thought this was an
easy process, until I was tasked to develop SOPs. Then, I learned.)
And, the system of development must provide for revision, as we learn shortcomings, problems, etc. Part of this process must include a channel
for feedback from the end users. In other words, the SOPs have to work!
Second step: Proper and thorough training in these SOPs. Too many less-than-legitimate operators take this step for granted. "Here, read the
book and carry on." This doesn't work. "Spoon feeding" is the key.
Third step: In management terminology, this is the 'control' step. The
operator must monitor and evaluate the compliance process. If there is a problem, the reason 'why' must be determined. It is a very common mistake by management types to blame individuals for lack of compliance. In many cases, the problem is with the SOP, not with the individual. It takes a clever managment person to delve deeply into why the world is not turning as planned.
411A is correct, although he did not go into such detail to articulate his communique. The only caution I have is that, before we condemn an individual, we must first look at the total picture, the SOP itself, the training process, and most importantly the control process.
It's been my experience (almost 40 years) that, in most cases, the problem is with the system, not with the individual.
Show me an airline with good SOPs....ones that work, are practical, relevant, etc., and I'll show you an airline that has very few incidents/accidents. Following the three steps listed above will ensure that things like this (the topic of this thread) do not occur in line flying.