37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1196190 |
Time | |
Date | 201408 |
Local Time Of Day | 0601-1200 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Aircraft 1 | |
Make Model Name | Citation X (C750) |
Operating Under FAR Part | Part 135 |
Flight Phase | Takeoff |
Person 1 | |
Function | Captain Pilot Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy |
Narrative:
This is my second week operating with the new SOP's. The training and implementation have been nothing short of a disaster. Last trip; neither of us had received any training on the SOP's; and the self-study was completely insufficient. This week; both of my flying partners had received training and were attempting to help me learn the new SOP's but have different interpretations on how they were to be applied and the written guidance did not clear up the issues. The new; and untrained; procedures are horribly distracting. At one point; we were so distracted by the new calls; we could not remember whether or not we had been cleared to takeoff. On two occasions; we had radio frequency problems because of the switching of #1 to primary; which is awkward for the cockpit design. In one case; because of old habit patterns; my co-captain was setting up the radios for ATIS and the FBO; and accidentally switched the #1 radio frequencies; losing both the current and former ATC frequencies. We had to look at an approach chart to regain contact with ATC. (We were off frequency for a very short period of time - maybe 1 minute- and as far as we know there were no missed calls; and no loss of separation; but it's embarrassing.) the problems are made worse because of the frequent changes of SOP's. Many crews I've flown with (and myself included) were just barely proficient with the last changes to the sops and now we're further confused by the latest. The calls in the cockpit are a mix of 3-4 revisions; none a 100% what is the correct callout. The TR check is an invitation for [an excursion]. Many will ignore the new policy completely; considering it unsafe (and I think it is unquestioningly unsafe!); others will begrudgingly do it; while commenting on how unsafe it is. The new sops have some good things in them; but the complete lack of training and half-hearted implementation plan have created an unsafe environment. What could have been positive; if trained and implemented well; has become a hazard for crews; passengers and innocents on the ground. I feel lucky that the worst mishaps this week were a couple radio mis-tunings and having to ask repeatedly if we were cleared for takeoff or landing (since we were so distracted by the new procedures/callouts). The poorly conceived changes; lack of meaningful training and haphazard implementation are aligning the swiss cheese; and removing barriers to unsafe conditions. I do not know how to repair this... It seems like attempting to put the toothpaste back in the tube. The first two immediate changes are that the TR check should not involve the pilot flying's hands leaving the throttles. The way we had done the checks for years is the far superior method. This current method is an invitation to put a plane off the side of a taxiway. Second; we should go back to the #2 radio being primary. While I understand the rationale for it the other way; and actually think the rationale is not bad; decades of practice and the configuration of the aircraft are better suited to #2 being primary. As for the rest of the SOP changes; maybe the entire fleet needs to be parked until the crews can be adequately trained. And in the future; abrupt changes should not be made like this... It's just not safe.
Original NASA ASRS Text
Title: Business jet Captain laments new SOP's that have been implemented without any formal training and only a written guide describing how the new procedures should be accomplished.
Narrative: This is my second week operating with the new SOP's. The training and implementation have been nothing short of a disaster. Last trip; neither of us had received any training on the SOP's; and the self-study was completely insufficient. This week; both of my flying partners had received training and were attempting to help me learn the new SOP's but have different interpretations on how they were to be applied and the written guidance did not clear up the issues. The new; and untrained; procedures are horribly distracting. At one point; we were so distracted by the new calls; we could not remember whether or not we had been cleared to takeoff. On two occasions; we had radio frequency problems because of the switching of #1 to primary; which is awkward for the cockpit design. In one case; because of old habit patterns; my Co-Captain was setting up the radios for ATIS and the FBO; and accidentally switched the #1 radio frequencies; losing both the current and former ATC frequencies. We had to look at an approach chart to regain contact with ATC. (We were off frequency for a very short period of time - maybe 1 minute- and as far as we know there were no missed calls; and no loss of separation; but it's embarrassing.) The problems are made worse because of the frequent changes of SOP's. Many crews I've flown with (and myself included) were just barely proficient with the last changes to the SOPs and now we're further confused by the latest. The calls in the cockpit are a mix of 3-4 revisions; none a 100% what is the correct callout. The TR check is an invitation for [an excursion]. Many will ignore the new policy completely; considering it unsafe (and I think it is unquestioningly unsafe!); others will begrudgingly do it; while commenting on how unsafe it is. The new SOPs have some good things in them; but the complete lack of training and half-hearted implementation plan have created an unsafe environment. What could have been positive; if trained and implemented well; has become a hazard for crews; passengers and innocents on the ground. I feel lucky that the worst mishaps this week were a couple radio mis-tunings and having to ask repeatedly if we were cleared for takeoff or landing (since we were so distracted by the new procedures/callouts). The poorly conceived changes; lack of meaningful training and haphazard implementation are aligning the Swiss cheese; and removing barriers to unsafe conditions. I do not know how to repair this... it seems like attempting to put the toothpaste back in the tube. The first two immediate changes are that the TR check should NOT involve the pilot flying's hands leaving the throttles. The way we had done the checks for years is the far superior method. This current method is an invitation to put a plane off the side of a taxiway. Second; we should go back to the #2 radio being primary. While I understand the rationale for it the other way; and actually think the rationale is not bad; decades of practice and the configuration of the aircraft are better suited to #2 being primary. As for the rest of the SOP changes; maybe the entire fleet needs to be parked until the crews can be adequately trained. And in the future; abrupt changes should not be made like this... it's just not safe.
Data retrieved from NASA's ASRS site and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.