There are certain seminal events that will forever be etched in our minds. For me, the first of such indelible memories was the day I got into Ms. Henderson’s carpool on a fall Friday afternoon. I was in the second grade. As she pulled away from the curb, she rolled down her window and shouted to another carpool mom. “Is it serious?” I remember it clearly, although I was only seven years old. President Kennedy had been shot.
Nearly four decades later, I was a passenger on a flight to Seattle to attend a safety conference. After a brief nap, I opened the window shade and admired the beautiful clear fall-like day. Within minutes, I noticed the sound of the Airbus’s CFM56s being reduced significantly. I thought it was odd to be getting a flow control speed reduction while some 2,000 miles from the destination. A few minutes later, a pilot’s announcement left more questions than answers: “Ladies and gentlemen, this is the captain. Due to a situation not related to this airplane, our dispatch has directed us to land immediately. We will be landing at St. Louis in about 20 minutes.” A flight attendant then came by and asked: “You’re one of us, right?” She probably spotted my crew tag as I boarded. When we landed, the taxiways and ramps were already full of airplanes that wouldn’t normally be at STL, including a Delta Tri-Star. I called my wife as soon as I could get a cell signal. “What is it?,” asked an older woman who had turned around in the seat ahead of me. “It’s bad. Really bad.” It was Sept. 11, 2001.
Seven years before that, my wife and I were in room 427 of the Richland Memorial Hospital. Our 7 lb., 11 ounce daughter had been born the day before. Until this day, I never had the occasion to change a diaper. So, around 7 pm I found myself attempting a chore that I would master over the next few years. In the middle of this unfamiliar task, the phone rang. My wife grabbed it. “It’s Dad. He wants to talk to you about a USAir crash in Charlotte.” I murmured something like “USAir hasn’t had a crash in Charlotte. I can’t talk right now.” She pushed back, saying that he really needed to talk to me. Then it struck me like a lightning bolt--maybe he knows something I don’t know. The call was short and somber. USAir 1016 had departed from our hometown and crashed on a botched go-around attempt at Charlotte. Furthermore, his son-in-law, my brother-in-law, was believed to be on that flight. We had no idea if he was alive or dead. Thirty-seven of the 57 occupants lost their lives. This was the fourth fatal crash for the airline I worked for in less than five years. A fifth would come only 69 days later. That next one claimed 132 lives.
NTSB’s investigation of flight 1016 noted the lack of adherence to standard operating procedures (SOP), including the sterile cockpit rule. “While the lack of strict adherence to procedures did not have an adverse affect [sic] on the enroute portion of the flight, the nonstandard operating practices during the final phase of flight might have caused the pilots to lose situational awareness during the approach.” In the ensuing legal fight, a plaintiff’s expert testified that the crew violated procedures 35 times in a 30-min. flight, including sterile cockpit violations and failure to make required callouts.
The investigation further highlighted, however, that lack of standardization and noncompliance with SOPs was not just problematic on this particular flight--it was more a reflection of the overall nature of USAir’s flight operations and training. For example, check airmen interviewed by NTSB indicated that individual pilots at the airline had different methods of accomplishing checklists. To make matters worse, FAA and USAir management were aware of inconsistencies with flight crew procedural compliance, according to NTSB, but failed to adequately address it. On one flight with an FAA inspector on the jumpseat, the captain didn’t call for the descent checklist. After waiting for several minutes to see if the crew would do the checklist, the inspector tapped the captain on the shoulder to remind him. The captain responded by saying he had a better way of doing it.
Without a strong and stringent focus on standardization and compliance, things can (and usually will) get loosey-goosey over time. For instance, in the six years preceding the crash, the company had bought legacy PSA Airlines, and shortly thereafter, legacy Piedmont. If ever there was a clash of cultures, this was it. We had the old Northern-based Allegheny/Mohawk culture that formed USAir several years earlier, which had merged with West Coast PSA, all jammed in with the Southern culture of Piedmont. Six weeks after the Piedmont merger, the combined airline suffered the first of five fatal crashes. The airline was hemorrhaging cash, resulting in a massive fleet rationalization (aka: parking and selling planes), talk of pay cuts and furloughs, and even rumors of the airline going out of business--which it almost did. Perhaps in times like this, it’s easy, but not acceptable, to take eyes off standardization.
After the fifth fatal crash, USAir became very serious about enforcing standardization. It had no choice--the airline could ill afford another accident or newsworthy safety issue. A damning but accurate New York Times article went into excruciating detail about the company’s safety woes. That article alone was said to have cost the airline $150 million ($290 million in today’s dollars) in lost revenue. Customers were turning away in droves and avoiding flying USAir.
From this point forward, the word from the very top of the organization was that there was only one way to conduct a checklist; cockpit callouts were to be precise, crisp, and verbatim, as specified in the manual; we will fly the way we train; and, if nothing else, we will be standardized.
It was a real wake up call. We always had been told how great and professional we were. Now--armed with statistics that compared us with other carriers on numbers of accidents, FAA violations, runway incursions and altitude busts--we collectively realized that standardization and compliance needed to improve. Immediately. And, fortunately, it did. From that point forward, the airline ran a very standardized operation.
I left the airline several years later to become head of a small Fortune 500 flight department. Although I was no longer with USAir, the lessons of the past remained with me. One of the first tasks was a collective effort by all our pilots to agree on SOPs, including callouts. We developed dialogue boxes, as spelled out in FAA Advisory Circular 120-71A, to specify when, where and how certain items were to be conducted. Despite unanimous agreement that this was how we would operate, I noticed we really weren’t following our SOPs precisely; there was still a lot of variability. Anyone who has studied quality management knows that variance is the enemy of quality. We were falling into the trap of having an immaculately written FOM simply becoming another dusty manual on the shelf. We recalibrated. I discussed with our pilots that, while we weren’t striving for perfection, we were seeking precision with SOPs and callouts. After each trip, pilots debriefed standardization and SOP compliance, along with three other items. We appointed a standards pilot who would give us an annual checkride.
Standardization became one of our departmental incentive bonus goals. If one pilot didn’t pass the standards ride, none of us in the department, including me, would receive our annual bonus. We put our money where our mouth was--we would run a standardized operation.
Nearly two years into my tenure there, I was nominated and confirmed to be vice chairman of the NTSB. After I left, the company began pursuing IS-BAO registration, ultimately achieving IS-BAO Stage 3. For each audit, the IS-BAO auditor commented favorably on the department’s focus on standardization and compliance.
I strongly believe a hallmark of professionalism is adhering to procedures and regulations. How standardized is your business aviation department? Do you have detailed SOPs, including what callouts are to be made and when? If so, how closely are you and others adhering to them? How do you ensure compliance? Do you carefully follow the sterile cockpit rule? Ask yourself and your colleagues these questions. If you’re not getting the right answers, don’t wait for an accident to fix it.
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