When “SOP” Fails: Disseminating Risk Assessment in Aviation Case Studies and Analysis

Abstract

In the early 1990s, a regional jet taking off from LaGuardia airport with ice and snow on the wings crashed into a nearby bay and killed 27 passengers and crew. The accident of US Air Flight 405 is studied critically in this review as a result of incomplete identification and dissemination of the risks involved in operations under icing conditions. The improper system risk dissemination and mitigation led the crew of USAir 405 to believe they were in a condition for a safe takeoff. In the larger context outside of this accident, unidentified hazards resulting from poor communication and company dissemination are still an everyday threat. I argue that this
disconnect is a causal factor in Normalization of Deviance. Contemporary examples of safety incidents are used to support this argument and introduce possible new areas for monitoring and research. The author argues that companies should employ techniques to open new policies
up for testing and feedback before being implemented as policy or standard operating procedure.