SE194: Airplane State Awareness - Standard Operating Procedures Effectiveness and Adherence

Background

The purpose of this Safety Enhancement is to reduce the risk of loss-of-control accidents by having Air Carriers develop and implement improved SOPs (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:

  1. Review, and update as needed, current SOPs for consistency with the CAST Plan, manufacturer recommendations, and air traffic control (ATC) procedures;
  2. Assess level of adherence to current SOPs, identifying possible reasons for insufficient adherence to certain procedures;
  3. Develop training programs to provide pilots with rationale for SOPs, focusing on those with lower adherence rates.

Related Implementation Plan

Detailed Implementation Plan

Related Safety Enhancements

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