2-1 CHAPTER 2. DETERMINING WHEN PROCEDURES NEED TO BE DESIGNED
OR MODIFIED
2.1 Requirements for Procedures. Operators are required to provide flightcrews with operating procedures per the applicable regulations as identified in the related regulations section. Although an Original Equipment Manufacturer (OEM) will typically supply its customers with suggested procedures and checklists for its equipment, operators may choose to develop, or modify, the procedures and checklists provided by the OEM. Some procedures may require a “No Technical Objection” from the OEM to modify them.
Also, some procedure modifications may require acceptance or approval from an operator’s principal operations inspector (POI). Operators should work with the OEM and FAA to determine if involvement in a SOP modification is necessary.
2.2 Modifying OEM Procedures. Procedures and checklists published by the OEM are designed to reflect that manufacturer’s flight deck design and operating procedures. They promote optimum use of aircraft features as envisioned by the designers, but may be generic in their applicability. Potential factors which may drive changes to OEM procedures and checklists include new or modified equipment, changes to the operational environment, company mandated procedures, standardization among related fleets, observed operational problems, incidents, accidents, or airline mergers.
3-1 CHAPTER 3. CREATING A PROCEDURE DEVELOPMENT PROCESS
3.1 Characteristics of Good Procedures. A well-designed procedure aids flightcrews by specifying a sequence of actions that, if followed, helps ensure that the primary task will be carried out in a manner that meets the basic guidelines of being clear, correct, reliable, and robust.
In general, as a minimum, good procedures cover the following elements:
• What the procedure is designed to accomplish.
• When and under what conditions the procedure should be executed.
• Who is responsible for executing each step in the procedure.
• How, in sufficient detail, the procedure is to be performed.
• How to confirm the procedure has been accomplished properly.
3.2 Collaborating for Effective SOPs. Collaboration can improve the effectiveness of SOPs. Partners in the collaboration could include representatives of the aircraft manufacturer, pilots having previous experience with the aircraft or with the type of operations planned by the operator, training organizations, and representatives from the FAA. Procedure developers should pay close attention to the approved Airplane Flight Manual (AFM) or Rotorcraft Flight Manual (RFM), to AFM/RFM revisions and operations bulletins issued by the manufacturer, and to the applicable FAA Flight Standardization Board (FSB) report. It is especially important for a new operator to establish a periodic review process that includes line flightcrews. Together, managers and flightcrews are able to review the effectiveness of SOPs and to reach valid conclusions for revisions. A trial period might be implemented, followed by feedback and revision, in which SOPs are improved. The review process will be meaningful and effective when managers promote prompt implementation of revisions to SOPs when necessary.
3.3 Resources to Develop SOPs. The procedure development process should start with a careful analysis of the factors driving the need to develop or modify a procedure and the implications of these factors.
Procedure developers should research all available sources of information that pertain to the process or procedure being developed or revised. This may include reviewing data from an Aviation Safety Action Program (ASAP) or a flight operations quality assurance (FOQA) program. Procedure developers should also understand the entire system of procedures and how they fit within the framework of existing policies, guidance, and the operator’s overall operational philosophy. Any new process or procedure should be consistent with that framework.
Employee groups who will be affected by the procedures in question may also add value in the development process. Procedures which interface with other employee groups should be coordinated accordingly.
4-1 CHAPTER 4. WRITING PROCEDURES
4.1 General Guidelines. Procedures should be communicated and trained effectively after they are developed.
4.1.1 Information to Include. Include only the information needed to validate it is the correct procedure to use and information to properly execute the procedure. While it is important to document and communicate the rationale behind the procedure design, this information should be provided in a separate training manual or other document.
4.1.2 Avoid Visual Clutter. Include supplemental detail only when necessary. When the addition of supplemental information is necessary, separate the supplemental information from the presentation of the actual steps to be accomplished.
4.1.3 Use Plain Language. Use simple English; the use of uncomplicated wording will increase comprehension while reducing ambiguity.
4.1.4 Use Short Sentences. Break long sentences into short sentences with a simple sentence structure.
4.1.5 Use Active Verbs. Sentences with active verbs (e.g., “Do X”) are easier to read and less likely to be misunderstood than sentences using passive verb forms (e.g., “X should be done”).
4.1.6 Write Steps as Imperatives. Imperative commands are direct; they tell someone what to do, and are often used when giving instructions. Avoid negatives when possible.
Negative statements are difficult to read and if it is missed, the meaning of the sentence will be misunderstood. When negatives are required, clearly specify what is being negated.
4.2 Organization.
4.2.1 General Organization. Procedures should be organized as simply as possible by order of tasking. Normal procedures are typically organized in sequence by phase of flight. When applicable, abnormal, non-normal, and emergency procedures should be organized by the triggering condition (e.g., smoke in the flight deck) rather than the potentially related system (e.g., electrical system).
4.2.2 Navigation and Place Keeping. Steps should follow a simple numbering system to assist pilots in maintaining their place in the procedure. Excessively detailed hierarchies should be avoided. Use headers when necessary to distinguish major sections of multifaceted procedures. Headers should provide useful cues to the purpose of the section of the procedure they address.
4.2.3 Lists. One step in a procedure may require that the pilot perform several actions or check several different indications. These components should be presented on separate lines in an indented numbered or bulleted list rather than in the body of the text.
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4.2.4 References. References to other procedures or appendices should be avoided unless necessary for completion of the procedure.
4.2.5 Memory Items. Memory items should be avoided whenever possible. If the procedure must include memory items, they should be clearly identified, emphasized in training, less than three items, and should not contain conditional decision steps.
4.2.6 Indices. An index should be provided for every procedure manual. In designing the index, ensure that the format accurately reflects the operator’s philosophies and training. If a procedure is identified in more than one way (e.g., if there are multiple indications), include all likely parameters in the index.
4.3 Vocabulary.
4.3.1 Use Words Consistently. Word use should be simple and consistent throughout the SOPs.
If possible, avoid creating new terms. Use words in their common English sense unless they have a widely accepted aviation-specific meaning. Match flight deck nomenclature.
4.3.2 Avoid Using Words with Multiple Common Meanings. Avoid using words with multiple meanings (e.g., use “correct” rather than “right”). Avoid using the same words as both nouns and verbs (e.g., display, position); if a word is to be used that could be a noun or a verb, choose one usage and apply it consistently (e.g., move the switch into the ON position vs. position the switch to ON).
4.3.3 Use Abbreviations Carefully. Only use abbreviations that are defined and commonly used in the industry (e.g., Vertical Navigation (VNAV), reference landing speed (VREF), air traffic control (ATC)), and avoid creating new abbreviations whenever possible.
Abbreviations should also only be used that are defined in the operating environment.
4.4 Numbers.
4.4.1 Use Arabic Numbers. Arabic numbers (e.g., 0, 1, 2) are easier to read than numbers that are spelled out (e.g., one, two). However, use spelled-out numbers for references when two or more different values must be presented in close proximity to other numbers
(e.g., use “one 10 kg weight,” rather than “1 10 kg weight”).
4.4.2 Include Units of Measurement. Do not specify numbers in greater precision than is necessary, or than can be read from instruments.
4.5 Format. In determining how to format procedures, the purpose, mode, and conditions under which the displayed procedures will be used must be considered. The presentation of procedures that are meant to be used on the ground at leisure in printed form may use a different format from procedures that will be read from a tablet computer in flight during turbulence or at night under time pressure. The presentation should be evaluated under conditions approximating those under which the procedure display might be needed.
4.5.1 Type Size. Use a type size that is large enough to be readable under all conditions likely to be encountered. In general, a 14- to 20-point laser printed sans serif font is adequate
4-3 for flight deck conditions. However, this should be tested under all potential operational conditions.
4.5.2 Line Spacing. Place sufficient space between lines of text. Using 25 to 33 percent of the font size between lines (e.g., 3 to 5 points space between lines using 14 point font) will make the text easier to read than if there was less space between the lines.
4.5.3 Font. Unusual or ornate fonts should be avoided.
4.5.4 Case. Use standard capitalization rules. Text in all capital letters is harder to read than text in lowercase. Use all capitals very sparingly and only for meaningful emphasis, or to represent labels that are commonly encountered in capitals (e.g., VNAV).
4.5.5 Grouping. Use visual techniques (e.g., white space created by extra lines, indentation) to delineate grouping of steps, lists, and the components of logic statements.
4.5.6 Justification. Paragraphs of text should be left aligned. Do not use right and left justified to produce aligned right and left edges, because it adds spaces between letters and/or words that make the paragraph harder to read.
4.5.7 Line Length. Traditionally, checklists have been formatted to resemble an index or table of contents with corresponding components (e.g., Challenge…Response) left and right justified and joined with dots or lines. This format is acceptable; however, excessively large gaps between the components should be avoided. The wider the gap, the greater the chance the pilot will inadvertently skip to the next line due to perceptual misalignment.
4.6 Place Keeping.
4.6.1 Title. Clearly identify the procedure by title (e.g., “Before Start”) and the objective of the procedure when it is not obvious from the title.
4.6.2 New Lines. Begin each step in a procedure, each element in a logic statement, and each item in a multiple item list on a separate line.
4.6.3 Bullets and Numbering. Use numbers, bullets, and lines, as appropriate, to indicate the beginning of each step. Using numbered lines can reduce navigation and place-keeping errors in the event that an interruption occurs. Numbered steps also facilitate navigation between procedures when it is necessary to “GO TO” a step within a procedure.
4.6.4 Continuation. Clearly specify if a procedure continues onto another page
(e.g., “Continues on Next Page”).
4.6.5 End. Clearly mark the end of a procedure with a standard symbol or wording
(e.g., “Checklist Complete”).
4.7 Emphasis. Emphasize cautions and warnings (e.g., CAUTION, WARNING), conditional words (e.g., IF, THEN), and important notes (e.g., NOTE). Timed events or steps that must be monitored for a period of time should be emphasized. Irreversible items should
4-4 be emphasized before the action is specified or taken. Techniques for calling attention to certain words or phrases should be used sparingly but consistently. Overuse of emphasis reduces its effectiveness and makes the procedure hard to read. Techniques for emphasis include:
4.7.1 Typographical. Typographical emphasis techniques include bolding, italicizing, underlining, and capitalization.
4.7.2 Graphical. Graphical emphasis techniques include framing, shading, coloring, and the use of standard symbols.
4.7.3 Spatial. Spatial techniques for conveying emphasis include using white space to group text and reserving places on the page or screen for selected types of messages.
4.7.4 Verbal. Verbal emphasis may be conveyed by using reserved words (e.g., Important, Note, Caution, and Warning).
4.8 Conditional Steps. In many procedures, some steps should be executed only when specified conditions occur. These conditional statements are a frequent source of confusion, particularly for novices, or with rarely used procedures. This problem can be alleviated by keeping the statements well structured, clearly phrased, and as short as possible.
Conditional statements should present all of the conditions clearly so that the correct choice is easy to identify. The steps that are associated with each condition should be grouped clearly. The end of this block of steps should be clearly identified and the action or procedure to be performed after completion of the block should be clearly specified. If there are embedded choices, then these subsidiary conditions also should be clearly delineated and the associated steps grouped in an unambiguous fashion.
Conditions should always precede actions. Actions that are irreversible should be identified in the condition preceding the action. Conditional statements may begin with one of the following words:
1. IF – use to indicate a condition that may or may not happen.
2. WHEN – use to indicate a condition that must be met before an action is taken and that condition is very likely to occur (e.g., “WHEN pressure reaches 120 psi THEN put gear down.”).
3. THEN – use to identify actions that should be taken when the specified condition occurs.
4. AND – use to combine two conditions that must be met before the action is taken.
5. OR – use to indicate that one or more of several conditions must be met before the action is taken.
4-5 If alternative formats are used, ensure they are used consistently and the intention is clear.
For example:
IF light x is lit THEN open valve y IF light x is NOT lit THEN open valve z Which also may be expressed as:
CHOOSE one:
Light x is illuminated ● Open valve y Light x is extinguished ● Open valve z
4.8.1 Complex Conditional Statements. Avoid using combinations of AND and OR whenever possible. In general, use separate steps instead.
4.8.2 Waiting, Continuous Actions, Repeated Actions. In some cases, an action must be continued or repeated until some condition occurs. In these cases, specify (1) what actions are to be repeated, (2) the conditions under which those actions should be stopped, and (3) whether the remaining steps in the procedure can be continued in the meantime. For example: “Hold button depressed UNTIL pressure reaches 120 psi, THEN GO TO step 5 in this procedure.”
4.9 Cross-References. Cross-references to other procedures should be avoided whenever possible. In most cases, a “Go-in, Stay-in” strategy should be used whereby all necessary steps for completing a procedure are included in that procedure. In some cases, this may prove impractical.
4.9.1 Explicit Reference. When used, cross-references should be explicit and use consistent wording.
4.9.2 Version Control. When references to other procedures are required, a system should be in place to monitor version control. Changes made to either the referring or referred procedures could affect the execution of the included steps.
4.10 Warnings and Cautions. Warnings and cautions in procedures should be used sparingly.
Overuse of warnings will decrease their effectiveness. Often “warning” is used to convey a more urgent or critical matter than “caution.” AC 25.1322-1, Flightcrew Alerting, contains definitions for these terms.
4.10.1 Components of Warnings and Cautions. Each warning or caution should identify a single hazard, the consequences of the hazard, and any critical time constraints. Actions should not appear in warnings or cautions.
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4.10.2 Placement. Warnings and cautions should be placed on the same page, and prior to, the steps to which they apply. Procedural steps should be graphically separated from warnings and cautions.
5-1 CHAPTER 5. DEVELOPING CHECKLISTS
5.1 General. Checklists are a special type of procedure. They are often the form into which extended procedures are distilled, and often the most common and most frequent form through which people interact with formal procedures. On the flight deck, checklists are an important tool in making sure that operational tasks are performed in a standardized fashion.
Checklists are of no value if the flightcrew is not committed to their use. Without discipline and dedication to using the checklist at the appropriate times, errors will inevitably occur.
Although it may be published in a manual, a checklist is designed for independent use so that the user will seldom need to reference that manual, especially after having been previously trained on the content therein. Checklists are used to ensure that a particular series of specified actions are accomplished in the correct sequence and to verify that the correct aircraft configuration has been established in specified phases of flight.
Checklists have been a significant part of the foundation of pilot standardization and flight deck safety for years. Such procedures, when applied in a disciplined and standardized fashion, are intended to support human performance regardless of circumstance. The checklist is an aid to the memory and helps to ensure that critical items necessary for the safe operation of aircraft are not overlooked or forgotten.
Checklists must be easy to access, easy to read, and easy to use. Checklists should provide enough information to enable the flightcrew to verify it is the correct checklist before they begin using it. Instructions should be concise, but sufficient information must be provided so that actions are performed correctly and essential issues are considered.
The checklist must accommodate the demands of high-workload phases of flight and the performance limitations experienced by humans when under stress. It should respond to the specifics of the situation but also assist crews in their management of the overall task.
5.1.1 Consistency. Operators should standardize checklist items and the sequence of those items to the maximum extent practicable, given possible make, model, and series (M/M/S) and variant differences across the fleet.
5.1.2 Type of List and Manner of Execution. For most normal procedures on the flight deck, a “flow” is conducted as a sequence of actions done from memory to configure the aircraft and its systems. The flow is followed by a checklist containing a subset of items from the flow that may be the most critical items within that flow and items that confirm the flow was done correctly.
5.1.3 Timing. Given the criticality of the checklist procedure, the crew’s ability to pay full attention to its execution is crucial. The timing of the checklist must be such that it would minimize the distractions and concurrent tasks. Timing of checklists should be designed not to interfere with other tasks and be resistant to interruption. For example, a “Taxi Checklist” that is to be accomplished during taxi might appear as an efficient use of crew
5-2 time, but it creates a high-risk situation because the crew cannot pay full attention to both the taxi and the checklist.
5.1.4 Roles. The role of providing the right cue at the right time for initiating the checklist is always assigned to one of the two pilots; usually, the pilot in command (PIC) on the ground and the PF in the air. Typically, the cue comes in the form of a verbal call (e.g., “before start checklist”), and serves to prompt the other pilot to retrieve the checklist.
Assuming a checklist for normal operation involves both crewmembers in a challenge-response method, both pilots would then be expected to direct their attention to the checklist task. The pilot responsible for leading the checklist begins by calling out (or “challenging”) the first item on the list. The other pilot verifies that the item has been done correctly and provides the relevant response. There are several variations on the theme of the challenge-response method: Following the response of the responding pilot, the challenging pilot may go on to challenge the next item, may also verify the state of the item, and may or may not provide a verbal response. The verification may or may not involve specific gestures such as pointing to the relevant switch, lever, or indication.
5.1.5 Initiation Anchor. The initiation of a checklist is best anchored in a clear cue that cannot be easily removed, obstructed, or forgotten, such as the occurrence of a particular event
(e.g., arrival at a point 2,000 feet prior to the hold-short line cues the initiation of the Before Takeoff checklist). Often, initiation of a checklist is left open, only constrained by a time window (e.g., Taxi checklist to be completed anytime during taxi) and acceptable circumstances (e.g., when both pilots are free of other duties). Cues for initiating checklists in these situations are often more of a personal technique among pilots, who use internal as well as external flight deck cues to aid them in remembering to initiate the checklist at the correct time. However, such “floating” checklist initiations create a high risk of failing to initiate the checklist on time and thus having to rush through it, or failing to initiate the checklist altogether. The importance of having clear and reliable external cues to trigger the initiation of the checklist procedure at the right pause point cannot be overemphasized.
5.1.6 Completion Signal. The checklist completion signal indicates that the checklist has indeed been performed in its entirety and leads into the next segment of activities. The most common completion cue is a verbal annunciation such as the “Before Taxi checklist complete” by the pilot who has been responsible for leading the respective checklist. The completion call should be written out as the last line item, or centered under each checklist. When the completion call is not explicitly listed on the checklist, a layer of redundancy is removed and the risk of omissions increases.
5.1.7 Checklist Verification. During the design of the checklist it is important to keep in mind that all checklist designs are subject to human error. Crewmembers may omit and skip checklist items or erroneously respond to a checklist at times believing that an item or a task was accomplished when it was not. At other times, crewmembers may see what they expect to see rather than what is actually accomplished or indicated.
One strategy that helps to overcome human error is to develop policies for using checklists which require stringent cross-checking and verification and reinforce those
5-3 policies through crew training programs. The procedures intended for checklist use should be clearly written in the operator’s operating manual and must be compatible with the operator’s CRM philosophy.
The policy should include, but not be limited to, the following items:
1. Flightcrew responsibilities for maintaining aircraft control, analyzing situations, and requesting the appropriate checklist in normal, abnormal, non-normal, and emergency situations.
2. The specified crewmember responsible for initiating each checklist.
3. The specified time when each checklist is to be initiated.
4. The specified crewmember responsible for accomplishing each item on the checklist.
5. The specified crewmember responsible for ensuring that each checklist is completed and reporting that completion to the crew.
6. Crewmember responsibilities for bringing to the attention of the PIC and the rest of the crew any observed deviation from prescribed procedures.
5.2 Methods for Managing Checklist Accomplishment.
5.2.1 Single-Pilot Aircraft. For single-pilot aircraft, operators should mount the Before-Takeoff and the Before-Landing checklists on the instrument panel. When aircraft characteristics allow, the operator should develop touch-verification procedures which include a requirement that the pilot touch each control to verify it is in the correct position.
5.2.2 Multi-Pilot Aircraft.
5.2.2.1 Flight-Related Checklists. Flight-related checklists should be accomplished by one crewmember reading the checklist and the second crewmember confirming and responding to each item, as appropriate. Exceptions to this may be the After-Takeoff and After-Landing checklists. While airborne the PF should not be distracted from controlling the aircraft flightpath to perform a checklist item that another crewmember can accomplish. Only one pilot should be in a head-down posture at any time the aircraft is in motion.
5.2.2.2 Verification. Crewmembers should be directed that when they observe that another crewmember is not taking or has not taken a required action, they are required to inform the crewmember.
5.2.2.3 Checklist Completion Tracking. The crewmember responsible for initiating the checklist should be responsible for ensuring that the checklist is completed systematically and expeditiously. This crewmember should be responsible for managing interruptions, cross-checking controls and indicators to ensure that the required actions have been accomplished, and reporting that the checklist has been completed.
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5.2.2.4 Callouts. A callout should be made by the pilot if he or she is accomplishing a task that requires him or her to be “heads down.” This helps ensure the other pilot is not heads down at the same time.
5.2.2.5 Critical Items. Critical items should be verified by both the PF and PM.
1. In the before-start phase, flight guidance and navigation items are considered critical items. Concurrence should be required from both pilots when the same setting is required for more than one device (such as computers, flight instruments, and altimeters). Inertial platform alignment and computer programming should be accomplished by one crewmember and independently confirmed by another. As many of these checklist items as possible should be accomplished and verified before the aircraft is moved.
2. In the taxi and pre-takeoff phases, aircraft configuration (such as flaps, trim, and speed brakes) and flight guidance items (such as heading, flight-director, altitude select panel settings, and airspeed cues) are also critical items.
Consideration must be given to non-standard operations such as deicing which may result in configuration changes from what was previously set.
3. On approach, flight guidance checklist items are critical. The PF and PM should be required to confirm and respond to these items when incorporated in a checklist. Concurrence should be required when the same setting is required on two separate devices (such as computers, flight instruments, or altimeters).
4. Checklist items that are critical in the before-landing phase vary with the type aircraft involved. The landing gear and flaps are critical items and should require a confirmation and response by both pilots when incorporated in a checklist.
5. A checklist should not be depended upon to initiate a change in aircraft configuration. Operators should key aircraft configuration changes to specific operational events (e.g., direct the landing gear to be extended at glide slope intercept). For any change in configuration, a command from the PF and an acknowledgment from the crewmember taking the action should be required.
5.2.3 Interruptions. Crewmembers frequently cannot complete a checklist because of interruption or an item on the checklist has not yet been accomplished. Operating procedures must be established to ensure that the correct checklist sequence is completed after an interruption. If the sequence cannot be re-established or the crew is unclear on where to resume the checklist, the appropriate section of the checklist should be reaccomplished from the beginning.
5.2.4 Representative Items. Representative items are selected items that represent a whole subset of flow actions such that if the selected item was performed, the whole subset must have also been performed. For instance, if all engine indications are in the green, the whole engine start sequence must have been done correctly; therefore, checking the engine indications can serve as a representative item for the engine start sequence.