STANDARD OPERATING PROCEDURES AND SAFE OPERATIONS

Introduction      What are Standard Operating Procedures (SOPs)? A letter by the US Federal Aviation Administration (FAA) aptly answered this question where in it was stated that, “SOPs are written, tested procedures that are applied uniformly and consistently within an organization and involve all aspects of flight, both normal and non-normal”. It further stated that “SOPs are widely recognized as a basic element of safe aviation operations”. Safety is one of the pre-requisites for mission accomplishment in aviation, and thus the importance of SOPs can never be under estimated.

Design of SOPs

The aircraft manufacturer provides the initial SOPs for the aircraft based on lessons learned from previous operating experience; analyses performed during design; experience gained during development and certification flight testing; and also experience from the route-proving program. These manufacturer-provided SOPs are adopted without change by an aviation organisation, or these are used as the basis for the development of customized SOPs that promote standardisation across the different aircraft fleets in service at the organisation. Company SOPs so developed reflect the organisation’s operating and training philosophies. Thus, SOPs represent the collective wisdom of the aviation community on how operations could be conducted safely.

To ensure safety, training and operations need to be consistent, implying that training and operations should both be conducted as per the SOPs. This can only happen if everyone in the organisation is convinced of the need to follow SOPs. Bringing about this awareness places a great responsibility on the flying supervisory staff.  Instructors and check airman of the operator are required to ensure that crews are made aware of the reasons for SOPs; are trained as per the SOPs, and are also required to enforce the same during routine line operations.

SOPs published by the operator normally include expected procedures that would be utilised during the flight profiles that are used by the operator, including pre & post flight procedures. SOPs lay down the most effective and efficient procedure to execute any task safely. New procedures need to be added to the SOPs, and redundant ones modified/ deleted based on requirements, and also based on experiences gained by the aviation community. To undertake this task, review of SOPs should be an ongoing task, ideally accomplished with suitable feedback from the end user, the flight crew.

All of this is done with an aim of ensuring safe aviation operations. It is now abundantly clear that safety is not dependant only on the training of the crew, but also on good crew coordination as well as optimum crew performance (or good CRM). This can best be ensured if the crew has a shared mental model of each task that is being undertaken. SOPs provide that vital link that can effectively ensure this shared mental model between crew members, with the least communications, because when every crew member is following SOPs, he/ she is aware of what needs to be done; when it needs to be done; and by whom.

To ensure that every crew member follows the SOPs, these procedures should be clear, comprehensive, and readily available to the flight crew members. In addition the crew members should be aware and convinced of the need to follow the SOPs. All this sounds logical but a study of aircraft incidents and accidents indicates that some of these have been caused due to the crew not following the SOPs.

Operational and Human Factors Involved in Deviations from SOPs

To ensure effective compliance with SOPs, it is important to understand why pilots intentionally or inadvertently deviate from the SOPs. In most cases of deviation from SOPs, the procedure that was followed in place of the published procedure seemed appropriate to the crew, for the prevailing situation, considering the information available in the cockpit at the time. However, it was later found that it was either inappropriate, or at best suboptimal. Experts cite the following factors and conditions as making it more likely that a deviation from SOPs will occur. Awareness of these factors can influence adherence to SOPs and may also be useful in developing corresponding prevention strategies.

• ·         Corporate culture (e.g., the absence of company management’s clear commitment to SOPs and standardization; double standard practices)
• ·         Ineffective or unclear company policies (e.g., regarding schedules, costs, go around, diversion, crew duty time, etc.)
• ·         Inadequate awareness/ knowledge of, or failure to understand the procedure, or action (e.g., quality of wording or phrasing; procedure or action being perceived as inappropriate)
• ·         Insufficient emphasis on strict adherence to SOPs during routine training and checks.
• ·         Insufficient vigilance (e.g., due to fatigue)
• ·       Distractions (e.g., due to cockpit activity)
• ·         Interruptions (e.g., due to ATC communication)
• ·         Task saturation resulting in fixation/ degraded multi-tasking ability or task overload leading to reduced attention.
• ·         Incorrect management of priorities (e.g., lack of or incorrect decision-making model for time-critical situations)
• ·         Incorrect CRM techniques, especially the absence of cross-checking, crew coordination or effective backup
• ·         Personal desires or constraints (e.g., personal schedule, press-on-itis)
• ·         Complacency or Over confidence

An Effective SOP

An effective SOP would need the active collaboration of all stake holders, at the formulation as well as the implementation stages. The following factors should thus be considered for creating effective SOPs: -

•  All crew members should be aware of the reasons for the procedure, and should also be convinced of the need to follow the same. It is a known fact that when flight crew members are so convinced, then they are more likely to follow the procedure, and also offer valuable feedback to improve upon an existing procedure, or  introduce a new relevant procedure.
•   All crew members should hold the belief that the procedure is appropriate to the stated flight situation, and would cover all the likely eventualities. This should be reinforced during effective training sessions conducted by the operator’s flight instructors/ check pilots.
•  The procedure should clearly lay down what needs to be done, by whom (PF/ PM), and when it is to be done. Each crew’s responsibilities would thus be clearly delineated.
•  The senior supervisors should set an example through word, and more importantly through their deeds that SOPs are to be followed. Any shortcomings/ misgivings about the procedure that are pointed out by the line crew should be discussed and remedial action initiated, if considered appropriate; otherwise the crew member should be provided feedback of the reason why the suggestion is not considered worthy of implementation.

 It has been seen that many a times SOPs are not consistently implemented, in that double standards are practiced by the crew and these are also condoned by the instructors/ check pilots/ managers. Flight crews follow the SOPs during training and check rides, but do it their own way during routine line operations. When this kind of a situation exists, it is an indication that the SOP is either not practical or effective for some reason. The reason for the deviation should thus be investigated and remedial action initiated.

Summary

Safety in aviation continues to depend on good crew performance. Good crew performance, in turn, is founded on standard operating procedures that are clear, comprehensive, and readily available to the flight crew. Development of SOPs is most effective when done by collaboration, using the best resources available including the end-users themselves, the flight crew. Once developed, effective SOPs should be consistently enforced during training as well as during line operations and ineffective SOPs should be continually reviewed and renewed. Double standards should not be permitted.

AIR TRANSAT ACCIDENT - 24 AUG 2001

Brief Details of the Accident

Flight TS 236 took off from Toronto at 0:52 UTC on Friday August 24, 2001 bound for Lisbon. There were 293 passengers and thirteen crew members on board. The aircraft was an Airbus A 330 registered as C-GITS that was manufactured in March 1999, configured with 362 seats and placed in service by Air Transat in April 1999. Leaving the gate in Toronto, the aircraft had 46.9 tonnes of fuel on board, 4.5 tonnes more than required by regulations.

At 05:36 UTC, the pilots received a warning of fuel imbalance. Not knowing at this point that they had a fuel leak, they followed a standard procedure to remedy the imbalance by transferring fuel from the port to the near-empty starboard tank.At 05:16 UTC, a cockpit warning system chimed and warned of low oil temperature and high oil pressure on engine no. 2. There is no obvious connection between an oil temperature or pressure problem and a fuel leak. Consequently Captain Piché and co-pilot DeJager suspected these were false warnings and shared their observations with their maintenance control centre, who advised them to monitor the situation.

Unknown to the pilots, the aircraft had developed a fuel leak in a fuel line to its starboard engine. The fuel transfer caused fuel from the operational side of the aircraft to be wasted through the leak in the engine on the other side. The leak, which averaged at 1 gallon per second, caused a higher than normal fuel flow through the fuel-oil heat exchanger (FOHE). The FOHE is designed to transfer heat from engine oil to fuel for both cooling and efficiency purposes. The increased fuel flow caused both the drop in oil temperature, as well as the rise in oil pressure that the pilots had observed earlier.

At 05:45 UTC, the pilots decided to divert to Lajes air base in the Azores. The crew were still unsure if they really had a fuel leak or not. They declared a fuel emergency with Santa Maria Oceanic air traffic control three minutes later.

At 06:13 UTC, while still 135 miles (217 km) from Lajes, engine no. 2 on the right wing flamed out because of fuel starvation. Captain Piché ordered full thrust from the remaining operational engine, and the plane descended to 33,000 feet (10,000 m), unable to stay at its 39,000 feet (12,000 m) cruising altitude with only one engine operating. Ten minutes later, the crew sent a Mayday to Santa Maria Oceanic air traffic control.

Thirteen minutes later, engine no. 1 also flamed out at while the aircraft was still approximately 65 nautical miles (120 km) from Lajes Air Base. Without engine power, the aircraft not only lost all thrust, but also its primary source of electrical power. The emergency Ram Air Turbine was deployed automatically to provide essential power for critical sensors and instruments to fly the aircraft. However the aircraft lost its main hydraulic power which operates the flaps, brakes, and spoilers.

Military air traffic controllers who were tracking the aircraft on their radar system guided the aircraft to the airport. While Piché flew the plane, DeJager monitored its descent rate – around 2000 feet (600 metres) per minute – and calculated that the plane had about 15 to 20 minutes left before they had to ditch the plane in the water. The crew sighted the air base a few minutes later. Piché had to execute a series of 360 degree turns to lose speed and altitude. Although they successfully lined up with Runway 33, they faced a new danger. The plane was on a final descent, going faster than optimal. Although they had unlocked the slats and deployed the landing gear, the airspeed was still too high. Additionally, the aircraft would be unable to use its thrust reversers to slow the plane during the landing.

At 06:45 UTC, the plane touched down hard 1,030 feet (310 m) down Runway 33 at a speed of approximately 200 knots (370 km/h), instead of the 170 knots (310 km/h) recommended for an unpowered landing. The aircraft bounced back into the air, but touched down again 2,800 feet (850 m) from the approach end of the runway and came to a stop 7,600 feet (2,300 m) from the approach end of the 10,000 feet (3,000 m) runway. With the operation of the emergency brakes, eight tires burst. Fourteen passengers and two crew members suffered minor injuries during the evacuation of the aircraft. Two passengers suffered serious but not life-threatening injuries.

The favourable outcome was partly attributable to the flight being rerouted at the last minute via a more southerly route across the Atlantic than initially planned, which brought the aircraft within range of the Azores.

Investigations

The Portuguese GPIAA investigated the incident along with Canadian and French authorities.

The investigation revealed that the cause of the incident was a fuel leak in the number two engine, caused by an incorrect part installed in the hydraulic system by Air Transat maintenance staff. Air Transat maintenance staff had replaced the engine as part of routine maintenance, using a spare engine, lent by Rolls-Royce, from an older model. This engine did not include a hydraulic pump. Despite the lead mechanic's concerns, Air Transat ordered the use of a part from a similar engine, an adaptation that did not maintain adequate clearance between the hydraulic lines and the fuel line. This lack of clearance — on the order of millimeters from the intended part — allowed vibration in the hydraulic lines to degrade the fuel line and cause the leak. Air Transat accepted responsibility for the incident.

Although pilot error was listed as one of the lead causes for the incident, it was the skill of the pilots, and of the military Air Traffic Controller in service at the time, 1st Sgt. José Ramos, that allowed the flight to land without fuel, causing only minor injuries to the passengers and minor damage to the airplane, which is still in service. The pilots returned to a heroes' welcome from the Quebec press.

The incident also led to the issue of Airworthiness instructions to all operators of certain types of the Airbus aircraft that stressed that crews should check that any fuel imbalance is not caused by a fuel leak before opening the cross-feed valve. The French Airworthiness Directive (AD) required all airlines operating these Airbus models to make revisions to the Flight Manual before any further flights were allowed. The FAA gave a 15-day grace period before enforcing the AD. Airbus also modified its computer systems; the on-board computer now checks all fuel levels against the flight plan. It now gives a clear warning if more fuel is being lost than the engines can consume. Rolls Royce also issued a bulletin advising of the incompatibility of the affected engine parts.

CHENNAI TO TORONTO

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I was booked on Emirates from Chennai to London via Dubai and on Air Canada from London to Toronto. I have a frequent flyer card for Emirates and admire the professionalism of this airline everytime i travel by it. Both the flights, from Chennai to Dubai and Dubai to London departed on time. The check in and other formalities were perfect. The service on board was very good and the latest aircraft ensured that we had good inflight entertainment during the journey. Dubai is always a treat to watch. A small sheikdom transforming itself into a major tourist and business destination. Dubai airport puts nearly all Indian airports to shame. Emirates, along with the other Gulf airlines like Qatar, Air Arabia, etc., are slowly but surely eating into the market share of the Indian carriers. Can our government stop this from happening by having market friendly policies?

Air Canada from London to Toronto was professional, but the service was not as good as Emirates. I guess most people working for Emirates are on a work permit that can be cancelled at any time, and that helps the Emirates bosses to keep employees on their toes. This is not to belittle the professionalism of Emirates but to put things in perspective.