SOP design and adherence

[Rwy in Sight]

Following the discussion of some recent aviation incident, where some posters discuss the crew attitude/performance regarding SOPs a question crossed my mind and I would like to have your input or comments.

To your opinion the crews tend to fail to follow adhere to the SOP why? Because it is a routine operation thus they know better, it is too complicated, it is unpractical on the normal daily operations under commercial pressure for an on time performance?

I am not saying that non adherence is a daily think and I am not try to blame the crews but I am trying to understand why it happens?

Many thanks for your comments!

Rwy in Sight

[bfisk]

Without knowing which incident you refer to above, there can be many answers to your question.

It is my belief that a procedure that is largely percieved as unnecessary or impractical, would over time tend to be disregarded. It might be because it it; or it might be because the underlying reason is not clearly communicated.

Take some examples, both from the flying, and non-flying world:

- You are driving your car in the US, where STOP signs are more common, and yield signs are less common. Approaching a stop sign, coming onto a crossing road with good visibility in either direction, and absolutely no traffic, you decide that you will keep a slow speed through the junction instead of coming to a complete stop. On one hand you know you are in violation, but at this particular junction, you positively determine there will be no danger, and you will not get caught. Does this stop sign help reduce accidents, in that particular junction, more than it creates a disrespect for stop signs, possibly causing them to be overlooked at other junctions where they may be very important?

- A nurse may, at some places, be required to show other nurses whenever remaining quantities of sedatives are disposed of (ie if you put half a shot of morphine into the sink, someone has to witness you). The hospital management has imposed a rule that this procedure shall now include all medication. However at a that particular ward, there is a shortage of nurses, and in with the patients interests in mind, that rule starts slipping. The nurses see that it is impractical to call on another nurse to throw away 1/2 tablet of ibuprofen/paracetamol/other, when his colleague is already busy. After a while this rule slip grows to include potent drugs such as morphine, and one day, when management finds out that morphine is being disposed of, they now tighten the screw and mandate that all drug discarding shall be witnessed and signed for by another staff member. Will this procedure be helping?

- An airline that prides themselves in high operational and safety standards, requires all their pilots to memorise ALL checklists, including abnormal and emergency drills (let's say a total of 100 checklist, with on average 3-4 items each). On a simulator check one pilots balls up the engine fire after takeoff and is reprimanded. He argues he did the best of his ability, and he then starts reciting other abnormal and emergency checklists, to show his commitment, and pride in his work. Whose fault is it that he ended up in a smoking hole?


There are other various reasons for procedure not being followed, but I think the above is very important to be mindful of when designing procedures. As long as there is no major grievances towards superiors, I think most people as willing and able to follow a procedure to the best of their ability; but such procedures must be smart, practical, and thought-out. I'm not defending the above three situations: you SHOULD stop at a stop sign, you SHOULD show the paracet to another nurse and have him sign for it, and you SHOULD memorise the engine fire checklist. I'm just saying you have to consider the human factor; you cannot write procedures for them as you write software code for a computer.

[safetypee]

A good reference for better understanding non adherence to SOPs is the report tilted “Bending the rules – why people break rules or fail to follow procedures – and what you can do about it”. Amongst the several authors are James Reason and Patrick Hudson.
There is an on-line copy in the CRM Developers Group forum at crm-devel : Neil Krey's CRM Developers Forum you will have to join the group to gain access to the files section; - there are many other safety/CRM references as well.

There is a briefing on Improving Procedural Compliance, and a Procedure Assessment Tool, both based on the previous reference, in the library at Aviation.Org (free registration), again there are several other useful references.

A range of resources can be found at ‘Hearts and Minds’ Hearts and Minds - in the ‘Managing Rule Breaking’ section. A significant part of this work was instigated by Patrick Hudson.

There is a very comprehensive toolkit from the Rail Safety and Standards Board which can be downloaded from the RSSB website as a WinZip file. The toolkit is 2.7 MB in file size and it might take a few minutes to download.
To download the toolkit and view the download instructions go to
http://www.rssb.co.uk/pdf/reports/re...it%20final.pdf
and then / also:-
http://www.rssb.co.uk/pdf/research_m...06/Toolkit.zip

Dan Maurino (ICAO) suggested that “deficiencies in standard operating procedures might be at the root of all violations”. I don’t have any hard evidence to support that belief, but my experiences from incident investigation suggest that procedural design is a major contributor along with crews not understanding a situation and thus choosing an incorrect course of action.
The latter ties in with the previous post and weaknesses in human behaviour.

[Grendel]

One of the things not mentioned in this thread but probably mentioned in the literature is the proper design of the procedure or action.

In the Demming method, the role of proper analysis of procedure and or "systems analysis" is critical. There are many simple procedures that do not require in depth analysis. There are however many that do.

The design and use of FMC's is a good example. A modern FMC is designed to ease the crew work load as far as Navigation is concerned. Limitations on the design of the FMC and the limited knowledge of engineers that built the system contribute to possible errors. Case in point is the Columbia crash of the AA 757 several years ago. There was confusion as to what fix they were navigating to.

In the US currently the FAA is attempting to gain additional airspace utilization by designing RNP RNAV departures. These departures are designed to allow simultaneous departures on close parallel runways with very accurate NAV separation. Depending on the FMC in use, there are built in hazards to this procedure. My company's old FMC's in our Boeings require extensive "work around" and programming to comply with these new RNAV departures.

Our Airbus fleet requires almost no modification. However despite this ease of use, last minute runway changes, a very common occurrence in LAX and ATL, can cause critical separation standards to be compromised.

Here was a problem that didn't exist until the new minimum separation departures came along. Now there are critical programming procedures that must be complied with or separation standards are not met. The earlier FMC's were not designed with this in mind and the programming procedure is
very error prone.

If a procedure is cumbersome or does not fit the flow of the work being done, or if the procedure actually hampers normal operations it is likely to be disregarded. The FAA needs to understand that the gain in utilization provided with RNP departure procedures needs to be tempered with a need by crews for no last minute changes requiring extensive reprogramming.

Demming learned early on that in the analysis of work systems those "work flow procedures" must support the job at hand and not detract from it.

The FMC RNP procedure is just one small example.

[Rwy in Sight]

Many thanks for your answers. All where useful particularly the last one!

Take care,


Rwy in Sight

[framer]

[quote]

To your opinion the crews tend to fail to follow adhere to the SOP why?

Important question and one that I often think about.

The other posters on this thread seem to be professionals in CRM or Human Factors....I am just an interested line pilot who gets the 6 monthly one day course.

One thing that I have noticed is that the attitude of the crews is heavily influenced by the how much the company invests in the crews in terms of training and also if the crews feel like the job is a long term prospect. At national flag carriers I get the feeling that crews feel it is worth while keeping up with changes and complying to SOP's because they are going to be there for a long while. While at contract jobs pilots seem more prone to running a mix of what they know and what the company expects.
I used to think that "company culture" was a silly buzz phrase but after moving through several carriers I see it is a very important and influential thing.

If a procedure is cumbersome or does not fit the flow of the work being done, or if the procedure actually hampers normal operations it is likely to be disregarded.

I agree. The crews are often under pressure to achieve things that are conflicting. For example, they are under pressure to turn around the aircraft in 30 minutes, and at the same time they are under pressure to comply with SOP's. Often you can only achieve one at the expense of the other. Now the correct thing to do in this situation is to run late in my opinion. But that goes against a lot of peoples personalities, so SOP's are compromised by shortening up briefings, walk-arounds, MEL implementations, rushing checklists, doing things out of order etc.
I think the company carries a lot of the responsibility in the above scenario which is played out thousands of times a day around the world. The pressure to carry out four 30 min turn arounds in one shift is immediate and the consequences of not achieving it are also immediate and obvious. The pressure to rigidly follow SOP's is there....but it's not so immediate and obvious. (ops will not ring you and ask if you are rigidly following your sop's, you won't get an email at home if you are a bit sloppy with your sop's, you won't loose your landing slot, the cabin crew won't complain, the pax won't complain your wife won't complaain etc)So the tech crew have to have a good understanding of the purpose of SOP's and their importance in order to not pay more heed to the pressure of the schedule.
So to answer your question, I think in some circumstances the crew don't follow sop's due to
a) conflicting company pressure and
b) lack of training/understanding re SOP purpose and importance...................................

[Bird380]

Guys then why airline operation slows down when flying by the book or following following SOPsstrictly.
Procedures are made to avoide incidents but then procedures starts becoming bigger and bigger and at times too complicated; pilots working against the time pressure will end up violating procedure even if he does not want to.

[turbocharged]

framer,

good insights. Thanks.

TC

[GlueBall]

Impractical reality

bfisk An airline that prides themselves in high operational and safety standards, requires all their pilots to memorise ALL checklists

There is no pride in such training culture. In fact it's unsafe and very dangerous. Because crews would have a propensity to do the entire drill by memory. Memory items must be strictly limited to only the essential immediate action items on the checklist. Any action beyond those must be read and followed according to the ORH, so as not to skip, or otherwise follow "by memory" important procedures out of sequence.

[Rwy in Sight]

Framer,

You said: "So the tech crew have to have a good understanding of the purpose of SOP's and their importance in order to not pay more heed to the pressure of the schedule".

I have a question here: does that means the crews will / should follow the spirit but not the letter of the SOP?

Thanks for the input about SOP and company culture - contract vs flag carriers.

Rwy in Sight

[bfisk]

GlueBall:

Thank you for your input. That was my point exactly.

You might want to re-read my post, and I may want to consider clarifying that all my three points are highly exaggerated for the purpose of provoking thought.

[framer]

I have a question here: does that means the crews will / should follow the spirit but not the letter of the SOP?

No I don't think so. I think that in 99% of cases SOP's should be followed to the letter. If they can't be then they should be re-written.

Many pilots don't understand how SOP's work. Sop's provide a 'framework'. If they are followed then both crew members know where abouts they are within that framework. If pilots start changing the order, omitting steps or even changing words it reduces the effectiveness of the Sop's and reduces their effectiveness. If an abnormal situation is developing and the flight is progressing within the Sops it is quickly apparent that something is not right. If the flight was operating outside of the Sops or only losely following them then it is difficult to tell if the abnormal is a result of the current way of operating or is an abnormal.
Even very simple things can cause extra unneccesarry workload, eg the standard call for raising the gear is normally "Gear Up". If you are flying with someone you don't know and English is their second language and you call "positive rate" and they say " ahhh yeah we take the gears up" you have to think to yourself "that wasn't what I was expecting...what did he say?? everything seems normal....ahh yes I know what he said..." and then you take the gear up. That may only take one sixteenth of a second for your brain o do that but it is the process you go through ad after a few days of it you will start just doing what you expect he/she wants without listening too hard. The other day I expected a Flap 30 call and selected flap 30....what he had actually said was something like " ahhh please I would like flap 25"
So following SOP's even down to exact standard calls is important in my view.

[GlueBall]

Captain framer . . .

I think that in 99% of cases SOP's should be followed to the letter. If they can't be then they should be re-written.

SOPs at most carriers include a stipulation that not all situations can be covered, just as checklists cannot address every conceivable problem; and that crews are not constraint from using common sense. Deviations, in fact, are allowed for good cause, but they must be briefed by the captain.

For example: The SOP specifies that "max thrust" must be used whenever a tailwind is present. But what would be the point of that if, for example, you were empty, departing on a 13,000 feet pavement with a 5kts tail wind? Would you burn up the engines just because the SOP says so?

If during short final approach at 300 feet AGL in daylight VMC you had a GPWS warning, would you go around just because the SOP says so?

If the SOP says the recommended taxi speed is 15kts and you are backtracking on a 13,000 feet runway, would you deliberately slow airport operations because of your SOP's recommended maximum 15kts taxi speed? For the sake of operational expediency, would you not taxi faster than 15kts on that same runway where you had just touched down at 150kts?

How many pages upon pages of your SOP book would you have to "re-write" so that practical reality and good common sense could be followed "to the letter?"

[Rwy in Sight]

I think I put the question slightly further down the line. Shouldn't the airlines write SOP that are both safe and line friendly. In other words who is to blame if the SOP is not followed: the crew or the one's designing the SOP.

I led the discussion on why the SOP's are not followed but it might be more usefull if we see also how we can help the crews to better follow the procedure.

Regards,

Rwy in Sight

[framer]

SOPs at most carriers include a stipulation that not all situations can be covered, just as checklists cannot address every conceivable problem; and that crews are not constraint from using common sense. Deviations, in fact, are allowed for good cause, but they must be briefed by the captain.

Of course.

The SOP specifies that "max thrust" must be used whenever a tailwind is present. But what would be the point of that if, for example, you were empty, departing on a 13,000 feet pavement with a 5kts tail wind? Would you burn up the engines just because the SOP says so?

No. I would reduce the thrust for several reasons. I said 99% of the time, that falls in the 1% in my mind.

If during short final approach at 300 feet AGL in daylight VMC you had a GPWS warning, would you go around just because the SOP says so?

If it was "Too low gear, or too low flap" then yes. But I do know what you're trying to say. That falls into two areas I mentioned,"the SOP's need to be re-written" and also the 1%. Three of the carriers I have worked for state in the SOP's that in daylight VMC the flightpath can be corrected without the terrain avoidance maneuvre. This is a good comon sense SOP. So rather than you being aware that common sense is called for, while you're new F/O "says captain we must go around"...you have a good SOP that everyone can follow.

If the SOP says the recommended taxi speed is 15kts and you are backtracking on a 13,000 feet runway, would you deliberately slow airport operations because of your SOP's recommended maximum 15kts taxi speed? For the sake of operational expediency, would you not taxi faster than 15kts on that same runway where you had just touched down at 150kts?

Really??? This is getting silly...
I would taxi at a speed that was appropriate , probably about 25kts actually and guess what, I wouldn't be breaching the SOP you just mentioned. I'd be confident of that because I know what "recommended" means. If the SOP says "you must taxi at 15kts whenever possible" then it falls into the catagory of needing to be re-written.

How many pages upon pages of your SOP book would you have to "re-write" so that practical reality and good common sense could be followed "to the letter?"

None at one airline I've worked at, a few at another and many at my current airline.
Are we on the smae page now Glueball? I think we probably were to begin with anyway. Common sense is common sense and if you have to breach SOP's on a regular basis to apply common sense then your SOP's need a work-over.

[Centaurus]

Quote:

If a procedure is cumbersome or does not fit the flow of the work being done, or if the procedure actually hampers normal operations it is likely to be disregarded.

A pertinent quote is: "Get away with anything long enough, and the perceived risk diminishes"

[Capt Pit Bull]

In my experience non compliance with SOPs usually stems from 2 primary areas.

1. The SOP is deemed not to be applicable. This can sometimes be valid, but has a general tendancy to become habit forming, not only in regards to that specific SOP (repeated it often enough and the pilot convinces themself that the way they do it is the way its supposed to be done!) but also more generally, as in 'SOPs are there for my guidance'.

Ultimately SOPs can not cover all circumstance and should be our servants not our masters, but if you are discarding them willy nilly then you are in danger of going past the occaisional excercising of good judgement into the territory of blind arrogance.


2. The SOP is unworkable. As in so completely unuseable that to attempt to do so would be immediately dangerous. In this case even the most disciplined pro-SOP pilot will decline to comply!


In my experience, 99.9% of deviations come in the former category and only cary a very small risk one way or the other (i.e. compliance may not always have been safer).

Very occaisionally the second category, usually followed by the procession of people heading for the chief pilot's door muttering 'what the !??!', followed by an SOP change. But in the intermediate period a lot of arguements and risk on the flight deck.

[beamer]

One problem with SOP's is that rather like Topsy they have grown and grown to the extent that there seems a procedure for everything - not only the important stuff but also the downright trivial and mundane. A generation of pilots who have known only one way of operating for just one Company believe that the SOP is the panacea for all evils. In reality they are a great building block towards safe aircraft operation but they do not cover all eventualities as I'm sure the likes of Capt Cheeseburger would testify. Sometimes you just have to utilise all that experience and commonsense that you have built up over a career to sort the problem; not easy for the new troops however who have no such background and to whom SOP's apparently have all the answers.

Should we employ SOP's - yes, of course. Should the training department allow themselves free rein to perscribe an SOP for every piece of minutiae in our everyday operation - no.

There used to be an expression - 'Minimum SOP's Maximum adherence' - I think that still has some value - discuss !

[411A]

One problem with SOP's is that rather like Topsy they have grown and grown to the extent that there seems a procedure for everything - not only the important stuff but also the downright trivial and mundane. A generation of pilots who have known only one way of operating for just one Company believe that the SOP is the panacea for all evils.

Very well said, my thoughts exactly.
Standard procedures are fine, so far as they go, however, slight variations to cater for certain pilot preferences (within reason) are not only allowed, but actively encourged at our small company.
One example.
On takeoff, the normal flap/slat selection is 14 degrees.
Optional, retract to 10 degrees at 400 agl at V2+10 minimum (then remaining retraction at either 800 or 1000 feet agl) OR leave at 14 degrees, and begin the entire retraction process at 800 agl OR 1000 agl.
Handling pilots choice, airfield obstacles/noise abatement permitting.

I like the former (flaps 10 at 400 agl) whereas our First Officer prefers the latter procedure.
Either is approved.

Another example.
Once flaps/slats are retracted, FMS thrust management can be engaged, at any altitude.
I prefer 5000 agl minimum.
Our First Officer prefers sooner.Either way is approved.
And, so it goes.
Handling pilots preference.

[DozyWannabe]

Do you think that it could be argued that the drive to create an SOP for everything grew out of the litigation-heavy US business climate? What I mean by that is that not following an SOP can give the airline an "out" when something goes pear-shaped, thus allowing them to attempt to limit liability?