SOPs 2015

DEPARTAMENTO DE ESTANDARIZACIONFebrero 2015STANDARD OPERATING PROCEDURES (SOPs)

Procedimientos y SOPsPara asegurar el cumplimiento efectivo con los procedimientos y SOPs publicados, es importante entender porque los pilotos se desvan de ellos en forma intencional o inadvertida.

En la mayora de los casos de desviacin, los procedimientos que se siguen en vez de los correctos, parecen ser los apropiados, considerando la informacin disponible.Constituyen la referencia para estandarizacin de tripulaciones y proporcionan el ambiente requerido para mejorar una comunicacin y coordinacion de tripulacin eficiente.

Objetivos de los Procedimientos y SOPsEstablecer un proyecto de accin comnReducir las ambigedades y riesgos de errorGarantizar un mejor reparto de tareasReducir la carga de trabajo de la tripulacinFacilitar el dominio de las acciones y erroresContribuir al conocimiento de la situacinReducir los riesgos de conflictos ICAO Operacion de Aeronaves IATA HFWG en Adherencia a los SOP

Esquema y Objetivos de la PresentacinEn pocas anteriores:Los incidentes y accidentes estaban relacionados con catstrofes estructurales, de motor oFallas de los sistemas o por el mal tiempoLas evoluciones tcnicas han llevado a una disminucin de fallas catastrficas

Actualmente:Las causas primarias y contributivas son en su mayora relacionados con la tripulacin (dos de cada tres)

La no adherencia a los procedimientos y SOPs como una amenaza:Las fuentes de error humano abundan: ADREP de la OACI, FSF ALARLas Auditoras de Seguridad en Lnea de las operaciones de ruta (LOSA) y la presentacin de informes confirman el aumento de errores de procedimientos

No Adherencia a los ProcedimientosFactores en accidentes de Aviacin 1970-2007ICAO ADREP

Auditorias de Seguridad en Operaciones de Lnea (IOSA)Frecuencia de los ErroresCuales son las consecuencias?

El Aumento del No Cumplimiento de los ProcedimientosLos procedimientos se estn haciendo cada vez ms para promover la conducta de la tripulacin hacia lo que se considera seguroUn diseo Duro" combinado con defensas procesales "suaves" animan las desviacionesLa sobreabundancia de procedimientos de trabajo standard se deriva principalmente en:la necesidad de adaptarse a los constantes cambios de hbitos y polticasla necesidad de aumentar la capacidad y eficiencia de las operacionesla necesidad de gestionar un entorno cada vez ms complejo? La comprensin del incumplimiento se puede hacer desde una variedad de ngulos: Cognitivo, de Comportamiento, Ergonmico, Gestin de la Seguridad y Anlisis de Datos.

23 Tipos de No Adherencia a los ProcedimientosNo percepcin de la informacin relevante (entrada)Percepcin errnea de la informacin (bsqueda de patrones)Diseo de Procedimiento (entrada, interpretacin)Experiencia Procesal / formacin (memoria a largo plazo)Los aspectos culturales (los factores que influyen)Personalidad aspectos / actitudes (factores influyentes)Los factores situacionales (factores influyentes)Heurstica de toma de decisiones (toma de decisiones)CRM (el conocimiento y manejo de atencin)Reducido a nueve subcategoras de medidas correctivas:ENTRENAMIENTOOPERACIONESDISEO

Ocho Tipos de No Adherencia de ProcedimientosCuatro tipos de violaciones basado en niveles de rendimiento:Violaciones de rutina: practicas comunes que se convierten en normas de grupoViolaciones de optimizacin: un desafo a las reglas que son muy restrictivasViolaciones situacionales: dictadas por el entorno inmediatoViolaciones excepcionales: circunstancias inusuales o no familiaresCuatro tipos de error basados en la taxonoma operacional:Errores de Procedimiento: intencin correcta/ ejecucin incorrectaErrores de Comunicacin: Trasmisin/interpretacion incorrectaErrores de desempeno: conocimientoand/or skill operational decision errors: unnecessary increase in risk

Violaciones Intencionales y No Cumplimiento No Intencional (errores)

Absence of Recognition Leading to Nonadherence to ProceduresWhat is absence of recognition other than a trap into lack of rigor?

Sheet1

EVENTRECOGNITIONPROCEDUREREMARKS

WARNINGEXECUTION

LOSS OF IRS DATA"ATT" FLAG IS NOTSOPs FOR NOT MOVING"ATT" WARNING WILL

AFTER TAKEOFFDISPLAYED ON PFD, WITHTHE AIRCRAFT DURING IRSBE DISPLAYED AS

A 300 - 600HONEYWELL IRU, IF A/C IS MOVEDALIGNMENTSOON AS EXCESSIVE

JUST AFTER PFD DISPLAYMOTION DETECTED

COMES ON

RETURN TO GATEFQI LESS THAN REQUIREDON PREVIOUS LEG, ARRIVAL FOB

ALT TO THR CLB /NOT CHECKED VERSUS DEPARTURE

OPEN CLB WITHFOB LESS TRIP FUEL PER SOP

AIRCRAFT DESCENDING

AT IDLE

A 320

BRUTAL DOORECAM DISPLAY RESOLUTION?SOP STATE "CHECK DIFFERENTIAL

OPENING AT GATEPRESSURE IS ZERO"

A 300 - 600

EVENTRECOGNITIONPROCEDUREREMARKS

CREW DIAGNOSISEXECUTION

NAVIGATIONNO F-PLN ABNORMALITYNO FOR F-PLN CROSSED

DEVIATION AFTERNOTED DURING COCKPITCHECK ?

GO AROUNDPREPARATION

NAV DEVIATION DETECTED BY ATCFOR NAV MONITORING

DURING SID ?

NAV LINE ANOMALY

OBSERVED ON PFD

RADAR VECTORS ISSUED TO

RECOVER F-PLN AT "TO WPT"

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EVENTRECOGNITIONPROCEDURECREW ACTIONREMARKS

CREWCONTENTS

VIOLENT OPENINGFAILURE TO RECOGNIZE"ON GROUND EMER / EVAC" PROCDOOR OPENING WITHOUTCAB PRESS

ON GROUNDTHAT A/C WAS STILLDOES NOT POINT THAT RAM AIRPOSITIVE CONFIRMATIONDIFFICULTIES +

A 300 - 600PRESSURIZEDEFFECT IS WITH CAB PRESSOF DEPRESSURIZATIONLAV / CARGO

IN AUTO ONLYCRM AND WORKLOAD ISSUESMOKE WARNINGS

EVENTRECOGNITIONPROCEDURECREWREMARKS

WARNINGCONTENTSACTION

RTO DUE TOECAM WARNING TRIGGERED BY

ENGINEPREVIOUS CREW AWARENESS

THRUST LOSSMESSAGE A.ICE ENGNOTE TO BE ADDED IN FCOMLATE RTO ACTIONNEED TO AVOID SUCH

A330VALVE OPENTO ANTICIPATESITUATIONS IN ANY

INTERLINK BETWEEN CREWECAM AT 80 KT /FUTURE DESIGN

A. ICE ENG 1 VALVE OPEN CREWAWARENESS MESSAGE ANDRTO AT 180 KT

AWARENESS MESSAGEECAM WARNING

ACTIVATED AT HOLDING POINT

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EVENTRECOGNITIONPROCEDUREPROCEDURECREW ACTIONREMARKS

CREWCONTENTSEXECUTION

VIOLENT OPENINGFAILURE TO RECOGNIZE"ON GROUND EMER / EVAC" PROCFAILURE TO COMPLETEDOOR OPENING WITHOUTCAB PRESS

ON GROUNDTHAT A/C WAS STILLDOES NOT POINT THAT RAM AIR"CAB PRESS MAN CTL"POSITIVE CONFIRMATIONDIFFICULTIES +

A 300 - 600PRESSURIZEDEFFECT IS WITH CAB PRESSPROC BEFORE CALLING EVACUATIONOF DEPRESSURIZATIONLAV / CARGO

IN AUTO ONLYAND DOING THECRM AND WORKLOAD ISSUESMOKE WARNINGS

"ON GROUND EMER / EVAC" PROC

Recognition Issue Leading to NonadherenceHow can recognition issue lead to procedural adherence?

Sheet1


CREWEXECUTIONACTION

ENG FAILED TOLOW POWERENG SET AT IDLE ONLYFOT AND FCOMFOT AND FCOM

REACH TAKE OFFHIGH FUEL LOWENG NOT SHUTDOWNREVISIONREVISION

POWER DUE TOVISIBLE FUEL LEAKPLANNEDPLANNED

FUEL LEAKFROM ENGINE

A 320

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EVENTRECOGNITIONRECOGNITIONPROCEDUREREMARKS

WARNINGCREW DIAGNOSISEXECUTION

ENG TAIL PIPE FIRENO ENG FIRE WARNINGENG TAIL PIPE FIREENG FIRE DRILL APPLIED

A 310TRIGGEREDREPORTED BY ATCENG TAIL PIPE FIRE NOT APPLIED

ENG FLAMEOUT DUEUNDETECTEDFUEL OUTR TANKQRH PROCEDURE NOTFUEL FEED

TO FUEL STARVATIONAUTOFEED FAULTLOW LEVELFOLLOWEDFROM OUTR TANK

A 300 - 600DISREGARDED AS SUSPECTEDFOLLOWING FAULT

SPURIOUS

THROTTLE LEVERTHROTTLE LEVER NOT AT IDLEAIRCRAFT PUSHED TRACTORNON COMPLIANCE WITH6 EVENTS SO FAR

NOT AT IDLENOT SET AT IDLEABOUT 10 FEET BACKSOPs FOR SETTING THR

DURING MESMESSAGE CREATEDLVR TO IDLE BEFORE MES

A 320

UNWARRANTED IFSDDECREASING OIL PRESSUREMISUNDERSTANDINGUNWARRANTED ENGINETYPICAL CASE OF

BASED ON DECREASINGBUT NO LOW OIL PRESSUREOF OIL PRESSURE AND LOPSHUTDOWNHURRIED REACTION

OIL PRESSUREWARNINGINDICATIONSCLIMB PHASE

A 320

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Procedural Subtlety Leading to NonadherenceHow can procedural subtlety lead to correct adherence?

Sheet1


CREW DIAGNOSISCONTENTSEXECUTION







CREW DIAGNOSISEXECUTIONACTION

ENG FAILED TOLOW POWERFOT AND FCOM

REACH TAKE OFFHIGH FUEL LOWENG NOT SHUTDOWNENG SET AT IDLE ONLYREVISION

POWER DUE TOVISIBLE FUEL LEAKPLANNED


A 320











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CREWCONTENTS















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Rushed Action Leading to NonadherenceWhat is rushed action other than premature decision making?

Sheet1


CREWEXECUTIONACTION

ENG FAILED TOLOW POWERENG SET AT IDLE ONLYFOT AND FCOMFOT AND FCOM

REACH TAKE OFFHIGH FUEL LOWENG NOT SHUTDOWNREVISIONREVISION

POWER DUE TOVISIBLE FUEL LEAKPLANNEDPLANNED


A 320

Sheet2

ENGINE FIREBECAUSE PARAMETERS WASECAM DISREGARDEDSPURIOUS WARNINGSPURIOUS WARNING

WARNING AND IFSDNORMAL, EXCEPT OQ "XX"SHOULD BE CORRECTEDSHOULD BE CORRECTED

PERFORMED 54CREW CONCLUDED TO SPURIOUSEFFECTIVELY ANDEFFECTIVELY AND

MINUTES LATERWARNING DESPITE 2 VISUALQUICKLY TO PREVENTQUICKLY TO PREVENT

A 330INSPECTIONSCREW DISREGARDINGCREW DISREGARDING

WARNING ACTIVATIONWARNING ACTIVATION

IFSD WHEN OP "XX"

AFTER 54 MINUTES

Sheet3



ALT DEV IN TURBULENCETURBULENCE READINESSIF TURB WAS FORECAST SP/ALT HLDCREW DISCONNECTED AUTOPILOT

WITH PROFILE MODEFROM FORECASTSHOULD HAVE BEEN PREFERRED TORATHER THAN LEAVING PROFILE

A 300 - 600PROFILE MODE(REVERSION TO SPD/ALT HLD)

AP + A/THR + PITCH TRIMNONESOPs NOT COMPLIED WITHAP DISCONNECTION BY STICK

DISCONNECTION +FOR PREVENTION AND RECOVERYFORCE SUSPECTED

ALT DEV IN TURBULENCEMANUEL RECOVERY AND

A 310AUTOPILOT REENGAGEMENT

TURB ENCOUNTERPOSITIVEQRH NOT APPLIED FOR OVERSPEEDSPEED BRAKES EXTENSIONTRAINING ISSUE ?

AND STALLPREVENTION AND RECOVERYAS SPEED UP TO MMO

A 310CREW RESISTED THE AUTOPILOTA-THR REDUCING TRUST

AT FL 350

SPEED DECREASING TO

STALL WARNING

OUT OF TRIM

CONDITION CORRECTED

BY F/O PNF

AP REENGAGED

RECOVERY AT FL330

COLLISION WITHBREAK PRESSURECREW FAILURE TO CONFIRM PARKING

JETWAY ON ARRIVALNOT VERIFIEDBRAKE PRESSURE BEFORE

A 320RELEASING PEDALS AND SHUTTINGRELEASING PEDALS AND SHUTTING

ENGINES DOWN, PER SOPENGINES DOWN PEMATURILY

Undue Interpretation Leading to NonadherenceWhat is undue interpretation other than biased decision making?

Sheet1



ENGINE FIREBECAUSE PARAMETERS WASECAM DISREGARDEDSPURIOUS WARNINGSPURIOUS WARNING

WARNING AND IFSDNORMAL, EXCEPT OQ "XX"SHOULD BE CORRECTEDSHOULD BE CORRECTED

PERFORMED 54CREW CONCLUDED TO SPURIOUSEFFECTIVELY ANDEFFECTIVELY AND

MINUTES LATERWARNING DESPITE 2 VISUALQUICKLY TO PREVENTQUICKLY TO PREVENT

A 330INSPECTIONSCREW DISREGARDINGCREW DISREGARDING

WARNING ACTIVATIONWARNING ACTIVATION

IFSD WHEN OP "XX"

AFTER 54 MINUTES


WARNINGEXECUTIONACTION

IFSD BASED ONSTEP DECREASE OF ENGINEDECREASING OIL QTY OR OIL QTYPRECAUTIONARY IFSDNO OIL LEAK

DECREASING1 OIL QTYADVISORY CALL ONLY FOR+FOUND BUT

OIL QTYMONITORING OF OIL PRESSDIVERSION14 QTS ADDED !

A 321AND OIL TEMP

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CREWCONTENTS















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From Recognition and Execution toEVALUATION of ConstraintsINTERPRETATION of ConsequencesIDENTIFICATION of the State of a SystemSEARCH for InformationDETECTION of Abnormal ConditionsAdapted from Rasmussen (1986)DEFINITION of a TaskFORMULATION of a ProcedureEXECUTION of ActionsSkillsRules RulesKnowledgeKnowledgeKnowledge

From Machine Minding to Decision MakingFrom a two-stage to a three-stage process

Causal Factors in Approach and Landing AccidentsInadequate decision making 74%Omission of action or inappropriate action 72%Nonadherence to criteria for stabilized approach 66%Inadequate CRM practice (coordination, cross-check, backup) 63%Insufficient horizontal or vertical situational awareness 52%Inadequate or insufficient understanding of prevailing conditions 48%Slow or delayed action 45%Flight handling difficulties 45%Deliberate non-adherence to procedures 40%Incorrect or incomplete pilot/controller communication 33%Interaction with automation 20% No go-around when required 17%

ConclusionsPilots use recognitive processes in the deployment of procedures, which may be accompanied by errorsEffective crews apply judgment to direct decision making Pilots natural risk-evaluation strategies help them to distinguish consequential errors from benign onesThis hinges on knowing how to trade off a variety of human factors Applying procedures can be repetitive, rather than sequential, even under heavy time pressureEffective crews avoid rushed overreactions, if at all possible

Conclusions (continue)The challenge of the future is to develop decision aids, cockpit and training systems that support rather than hinder the way good decision makers make decisions Experienced crews tap a vast reservoir of alternatives These procedures and SOPs should enable pilots to exercise discernment and good decision makingThey should be simple and accurate and with easy-to-assess consequences There is an enlarged role for pilots to be trained indecision making while using relevant procedures

Thanks you!!

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SOPs 2015

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