In the never-ending search for accident prevention’s silver bullet, NTSB member Robert Sumwalt said recently that reinventing the wheel isn’t always the best solution.
In remarks at the Flight Safety Foundation Corporate Aviation Safety Seminar (CASS) last month, Sumwalt said that sometimes simply reinterpreting the data on hand can provide fresh insights. “The NTSB conducted a safety study several years ago of 37 crew-caused accidents,” he explained. “Procedural errors, not making required callouts or not using the appropriate checklists were discovered in 78 percent of the reviewed accidents.”
After the crash of a Hawker 800 in Owatonna, Minn., in July 2008, the NTSB stated, “Well-designed cockpit procedures are an effective countermeasure against operational errors, and disciplined compliance with SOPs [standard operating procedures], including strict cockpit discipline, provides the basis for effective crew coordination and performance.” Sumwalt summarized, “That means we should begin focusing on how to get crews to more strictly adhere to SOPs.”
The big question, of course, is why pilots avoid SOPs. Sumwalt said, “An organization might never have developed any in the first place, or for some reason, the crews intentionally disregard those SOPs.”
He cited an Astra runway-departure incident at Dekalb-Peachtree Airport (PDK) in Atlanta. The investigation showed the company had no SOPs, therefore, no guidance on where to make any of the necessary callouts, or how to fly the approach, or even when to put the gear down. The reason was simply because the company began flying with just a single airplane and one fulltime pilot.
“Over the years, the fleet grew, but the infrastructure and procedures didn’t,” Sumwalt said, adding that the guiding document for developing SOPs, AC 120-71, says that “SOPs should be clear, comprehensive, and readily available in the manuals used by flight deck crew members.”