Procedural Compliance: Taking the Problem to Industry

By Earl F. Weener, PhD

Today, the NTSB hosted members of the Commercial Aviation Safety Team (CAST), a group of key government and commercial aviation stakeholders working toward improving commercial aviation safety. CAST meets bimonthly and is focused on finding ways to reduce the commercial aviation fatality risk in the United States by at least 50 percent from 2010 to 2025.

At this meeting—hosted in the NTSB Board Room—I was proud to introduce an NTSB produced video to highlight a safety problem we see emerging from our accident investigations: failures of procedural compliance. “Procedural Compliance” is on the NTSB’s Most Wanted List of critical transportation safety improvements.

During investigations, we too often find that pilots have deviated from or failed to follow procedures related to flying stabilized approaches. Crashes have occurred because pilots did not maintain a sterile cockpit, monitor critical flight parameters, including airspeed, or heed aircraft limitations. Our investigators have discovered missed or incomplete pre-flight briefings and checklists, and callouts.

Our video highlights findings from seven crashes, including the Asiana flight 214 crash in San Francisco, California, in 2013, and the UPS crash in Birmingham, Alabama, also in 2013—as well as some lesser known crashes.

The key takeaways from this video that we shared with this room of pilots, operators, and regulators included:

  • SOPs are an important barrier to crew errors caused by fatigue, distraction, stress, or inattention
  • SOPs must be trained
  • SOPs must be consistently applied and reinforced by both companies and pilots
  • The crew concept is an important part of SOPs

Everyone plays a role in ensuring procedural compliance—the airline operator, the regulator, and the pilots. They must work together to develop clear, concise and reasonable procedures; make sure train to the procedures; and make sure procedures are followed. By achieving consistent and strong procedural compliance, we can continue our success in making commercial aviation one of the safest forms of transportation.

Dr. Weener is a Member of the NTSB Board.

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