The Importance of Procedural Compliance

By Roger Cox

Image of crashed UPS cargo flight in Birmingham, ALThe August 14, 2013, crash of UPS flight 1354 in Birmingham, Alabama, was one of several recent accidents that involved crew deviations from standard procedures (often referred to as standard operating procedures—SOPs). The Asiana 214 accident in San Francisco in 2013 could have been avoided by closer adherence to standard procedures. Procedural non-compliance is also strongly implicated in several other recent accidents, including two wrong airport landings in 2014, still under investigation.

When I reviewed the facts of the UPS investigation, I was reminded of the familiar feeling I got when I was an airline captain planning and briefing an approach under potentially adverse circumstances. When things were not working out like I expected, I wondered if I was being set up for failure. My caution flags went up. Today, I ask myself how I would have felt and reacted, given what developed during the Birmingham approach.

Being a bit high on descent is allowed and pretty common, but it can throw your planning off. Going to a shorter runway than expected—and one not equipped with an instrument landing system—is another common complication. Having to conduct an unfamiliar non-precision approach at night, in the weather, just adds to the difficulty. The preflight and current weather information said the airport at Birmingham was essentially operating under visual flight rules, with good visibility and a 1,000 foot ceiling—but, alas, these were not the conditions. Finally, due to the proximity to the airport, software versions installed, and high descent rate, the automatic altitude callouts and terrain warnings—provided by protective systems we have come to expect in state-of-the-art airliners—weren’t enabled or were not as effective in alerting the crew to the seriousness of their situation. Yes, I thought, this situation was a set up for failure.

What should be a crew’s first defense against such adverse or unexpected situations? In my mind, it is adherence to standard procedures.

When crews develop the habit pattern of following checklists, doing briefings, and making callouts every time, they begin to do these things reflexively, even when they are stressed, distracted, and tired. The NTSB found that, while the crew adhered to good SOPs during preflight, climb and cruise, they made several critical errors and omissions during the approach that should have been caught if they had carefully and precisely followed procedures.

When a fatal accident occurs, everyone at the affected airline feels the pain. Pilots in particular feel it because they not only have had long friendships with the lost crew but they share a kind of kinship earned through common joys and hardships related to piloting. As they face the fact that they cannot undo what has happened, they ask how can we undo a similar tragedy in the future.

I hope the pilots who read the NTSB report on the UPS accident and watch the video released this week highlighting the issues that led to the UPS crash will take them in the spirit they were intended. Our goal always is to find a safer way in the future. To that end, I ask that we pilots recommit to standardization. In 2015, one of the NTSB’s Most Wanted List priorities is to Strengthen Procedural Compliance. This means: follow your SOPs. If you think one of your procedures is inappropriate or unwise, ask your company to consider changing it, but until they do, follow it and potentially avoid a catastrophic incident.

Roger Cox is a Senior Aviation Safety Investigator in the NTSB Office of Aviation Safety.

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