At the recent NBAA conventions National Safety Forum, NTSB Chairman Chris Hart cited the investigation of a Gulfstream G-IV crash on May 21, 2014 at Bedford Massachusetts that killed all seven aboard. Investigators blamed the crash on the crews attempt to take off with the control lock engaged. Analysis of the flight data recorder revealed the crew had not moved the controls through a normal pre takeoff control check in 173 of the 175 most recent flights.
How could this be? It seems so simple, the control check is on the pre takeoff checklist and mandated in the aircraft Standard Operating Procedure, or SOP. Clearly the trained crew had decided not to follow the aircraft standard operating procedures for some time.
Standard operating procedures (or standard work instructions – SWI’s) are any routine and repeatable way to accomplish a task. SOP’s naturally evolve for two main reasons:
They are the simplest or quickest way to do something.
They cover all the necessary tasks in the proper order, with little chance something is left out.
SOP’s minimize workload and ensure that the results of our inputs are predictable.
I see this every day on the shop floor. SOP’s are developed and we ignore them. Why?
We ignore our own SOP’s because we do not believe they really make a difference. What difference does it make if I follow them or not? Clearly, the Gulfstream crew did not believe the procedure really mattered to them. Maybe it was developed for a beginner crew who was just learning the aircraft. Certainly they do not apply to us. After all, we ignored them at least 173 times (probably more) and nothing bad happened.
How many times have we ignored our SOP’s and nothing bad happened? We got away with it once, twice, or many times? Maybe we just got lucky (as the Gulfstream crew did) or maybe bad things did happen and we did not know about it because they happened downstream from us and somebody else had to fix our mistake. Maybe a defect had to be repaired that we did not know about. Or, worse yet, maybe a defect found its way to a customer because we skipped a step.
We must all come to the realization that bad things DO happen when we ignore the SOP’s. Maybe not right away, and maybe we cannot see them, but they almost always happen, sooner or later. Following the SOP needs to become part of our behavior and our collective culture. And, not just following them sometimes, or when we are learning, but always. It is a matter of developing the discipline and the expectation of each other that this is how we operate, and how we treat each other. It is safer, more predictable, and produces higher quality products and services for our customers.
We define a problem as a deviation from standard, or a lack of a standard. Every task in your organization needs to have a standard and it needs to be followed every time. You may get lucky not following the standard 173 times. But sooner or later, you will not be so lucky.
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