Premium on Safety - Issue 45, 2022 - 3

SAFETY SPOTLIGHT
Maybe a checklist is outdated or redundant to the point that
items are blown over. Maybe there isn't a good procedure that
fits the situation. Maybe there's a better way to complete a task
than what's currently in the SOP. If we develop and foster habits
in ourselves to ensure that we're following checklists, making
callouts, conducting thorough briefings and honoring stabilized
approach criteria, we will not only be consistently safer pilots,
but also able to identify areas for improvement in our own
SOPs. If what we are doing isn't working or efficient, we should
bring it to the attention of our organization or the aircraft
manufacturer, always striving for improvement in ourselves and
the system.
As a pilot, why would you deviate from SOPs? Procedural
deviation usually starts as something much more benign. Call it
" procedural drift " or " bending the rules. " A relatable example
is driving a car consistently 5 to 10 mph faster than allowed by
law. Though speeding is against the law, police typically don't
enforce the law until you are more than 10 mph over the limit,
so essentially the violation has no consequence. The driver has
gotten away with it over and over again so the actual speed limit
that they self impose has drifted away from the true limit as
stated by law.
I challenge you to read through NTSB
accident reports and find an accident
that couldn't be stopped by a layer of
the " SOP Swiss cheese. "
When we become lax in one area, it's easy for that complacency
to bleed over to other areas. Non-essential conversation in the
sterile cockpit environment may limit the time for a thorough
and necessary approach briefing. Maybe that briefing becomes
abbreviated and critical information is left out. Maybe the
checklist wasn't completed and a crucial item was skipped.
Any one of these seemingly innocuous deviations could be
the critical layer of Swiss cheese that stops an accident from
happening. Each SOP is a slice of the cheese. When we deviate
from SOPs, we're eliminating one layer of safety whether we
realize it or not in the moment. As Vice-Chairman Landsberg
put it, " If you disrupt any one aspect of the accident chain, the
accident doesn't happen. "
I challenge you to read through NTSB accident reports and
find an accident that couldn't be stopped by a layer of the
" SOP Swiss cheese. " Yes, when we read accident reports, we're
working with a lot of 20/20 hindsight and can't possibly know
the full reason why SOPs were ignored or eliminated. But
by reading through some of the reports, we may be able to
imagine ourselves in a similar situation, recognize how we might
have started down a similar path, and identify SOPs that could
help us avoid a similar fate.
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So what do we do if we find ourselves in a situation where we
feel like we may go down a path of procedural non-compliance?
The NBAA's Safety Committee Professionalism Working Group
came up with several steps that we can take to mitigate that risk.
They are:
* Slow down. It has often been said in aviation that the fastest
thing that must occur in the cockpit is putting an oxygen
mask on. The rest of the issues can all be priorities. Numerous
line check airmen at a global Part 121 airline have stated
that once an EICAS/ECAM message occurs, they press
the stopwatch, and wait five to seven seconds in order to
evaluate the situation accordingly.
* Review the situation in question.
* Reassess the situation by using proper threat and error
management (TEM) and aeronautical decision making (ADM).
If threats are addressed, safe operations can resume.
If errors are detected, they are immediately repaired
and safe operations can resume.
* Come to an action consensus as a crew.
* Implement the solution and change the variables to enhance
ADM and crew coordination in the future. Review what
procedures do and don't work. Perhaps a verbiage change is
required.
What we practice becomes habit. Make sure it's a habit
worth keeping.
-Kristine Hartzell flies as Captain for a Fortune 500 company.
Premium on Safety - Issue 45, 2022

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