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SE194: Airplane State Awareness - Standard Operating Procedures Effectiveness and Adherence
|Category:||CAST SE Plan|
The purpose of this Safety Enhancement is to reduce the risk of loss-of-control accidents by having Air Carriers develop and implement improved Standard Operating Procedures (SOPs) to reduce flight crew member loss of airplane state awareness.
In a Commercial Aviation Safety Team (CAST) study of 18 loss-of-control accidents and incidents, insufficient adherence to SOPs was a factor in 15 events. To improve flight crew adherence to SOPs and reduce the risk of lost awareness of airplane state, air carriers should:
- Review, and update as needed, current SOPs for consistency with the CAST Plan, manufacturer recommendations, and air traffic control (ATC) procedures;
- Assess level of adherence to current SOPs, identifying possible reasons for insufficient adherence to certain procedures;
- Develop training programs to provide pilots with rationale for SOPs, focusing on those with lower adherence rates.