The Case for Better Standard Operating Procedures

Lessons Learned

In July 2008, a business jet operating under 14 CFR Part 135 touched down long on landing. In its analysis, the National Transportation Safety Board (NTSB) noted that, recognizing the deteriorating situation, the flight crew attempted a balked landing and initiated a go-around. With insufficient runway remaining and rapidly diminishing margins, the crew lost control of the aircraft, which crashed into a nearby cornfield. Both pilots and all six passengers were killed.

The accident was a stark reminder that in aviation, safety is rarely undone by a single failure. Instead, it is the culmination of missed cues, delayed decisions and systemic vulnerabilities. In the aftermath, the NTSB issued several safety recommendations aimed squarely at closing those gaps. Among them were calls for:

• More robust standard operating procedures (SOPs) for Part 135 operators
• Clear go-around guidance for turbine-powered aircraft
• Improved landing distance assessment guidance and requirements

At the center of these recommendations lies a fundamental truth: Well-designed and well-executed SOPs are among the most powerful safety tools available during flight operations.

History of Standard Operating Procedures

While it is impossible to pinpoint the exact moment humans began using SOPs, historians trace their early use to organized warfare in ancient civilizations, where consistency and predictability meant survival. In more recent history, the British Royal Navy formally documented procedures to ensure uniformity across fleets.

During the Industrial Revolution, SOPs became foundational across manufacturing and transportation industries to improve efficiency, repeatability and quality. The term “standard operating procedures” itself entered common usage in the 1930s.

Aviation, by its very nature, demands this level of procedural discipline. SOPs exist not to constrain skilled professionals, but to protect them from predictable human limitations, especially under time pressure, stress or high workload.

SOPs and the Swiss Cheese Model

James Reason’s Swiss Cheese Model of accident causation provides a powerful lens through which to understand aviation mishaps. The model illustrates how accidents occur when multiple layers of defense—each with inherent weaknesses—align in such a way that hazards pass through every barrier.

SOPs function as one of the most critical of these defensive layers. When properly designed and consistently followed, they help block the “holes” created by human factors, operational complexity and organizational shortcomings.

Importantly, the Swiss Cheese Model shifts the focus away from individual blame and toward systemic resilience. It recognizes that pilots operate within an ecosystem shaped by training, procedures, culture and organizational expectations. Weak or ambiguous SOPs represent latent conditions—hidden vulnerabilities that may lie dormant until the right combination of circumstances exposes them.

Threat and Error Management and the Undesired Aircraft State

Within Threat and Error Management (TEM) frameworks, the Swiss Cheese Model helps visualize how a flight can transition from a normal operational state into an Undesired Aircraft State (UAS)—a condition that, if not corrected, may lead to an accident.

SOPs play a dual role in this process. First, they help crews avoid entering a UAS by defining stable approaches, standard callouts, automation usage and clear decision gates. Second, they provide structured guidance to help crews recover from an Undesired Aircraft State when one does occur.

Consider a simple but powerful SOP example: a defined touchdown zone, such as threshold plus 500 feet to the calculated latest touchdown point. If it becomes apparent that the aircraft will not land within those parameters, the aircraft has entered a UAS. The SOP removes ambiguity by specifying the required response: Initiate a go-around.

In theory, decision-making becomes straightforward. There is no debate, no negotiation with deteriorating margins. In most cases, by executing the go-around in accordance with the SOP, the crew transitions the aircraft back to a normal, safe state.

SOPs as a Framework for Decision-Making and Decreased Error Rates

Beyond go-around criteria, SOPs establish the framework from which nearly all flight crew decisions and actions flow. They define:

• When and how checklists are run
• How automation is managed
• How briefings are conducted
• How crews communicate internally and with external resources
• Which profiles are used for normal and abnormal operations

Even single-pilot operators benefit from SOPs directed at individual performance, as they provide guardrails against cognitive overload and task saturation.

While no SOP can—or should—anticipate every possible scenario, high compliance with well-designed SOPs will decrease pilots’ or crews’ error rates substantially. One operator that designed their SOPs using guidance from NASA decreased their operational error rate by between 20% and 30%.

Designing SOPs for the Real World

A common misconception is that the most experienced pilots should automatically be responsible for designing SOPs. While operational expertise is essential, procedural design is a discipline in its own right. The most effective SOPs are developed either by individuals who understand both the operational environment and procedural science or by teams that combine subject matter experts with human factors specialists.

Research by NASA scientists—such as that presented in The Multitasking Myth by Barshi, Loukopoulos and Dismukes—demonstrates that flight operations rarely unfold in the linear, interruption-free manner assumed by many procedures. Distractions, task interruptions and competing demands are the norm, not the exception.

One critical consideration in SOP design is the placement of workflow triggers. For example, an operator determined that the descent flow and checklist should begin at FL240 rather than at the transition altitude where they had been initiating them. Doing so avoided overlapping the descent checklist with ATC handoffs, standard instrument arrival procedures, the transition altitude, etc.—reducing task competition at a critical phase of flight and avoiding a flow and/or checklist interruption.

This type of design thinking reflects an understanding of what crews truly encounter in the dynamic, complex, three-dimensional space they operate in.

Decades of operational research and SOP best practice design drove collective action in the aviation industry. A focused coalition of U.S. air carriers and training providers (including FlightSafety), in cooperation with The National Business Aviation Association (NBAA), convened throughout 2025 with a clear mandate: Create a comprehensive, globally applicable, set of standard operating procedures that would be available for all operators to adopt.

The initiative aimed to promote consistency, professionalism and operational excellence across business aviation, reinforcing high-quality practices that elevate safety and standardization worldwide. Developed in collaboration with the NBAA, aircraft manufacturers, operators and other leading training experts and approved by the FAA, the SOPs represent years of industry partnership dedicated to advancing aviation safety. Following extensive collaboration and review, the NBAA released Version 1 of the SOP guidance in October of 2025. The document is publicly available on their website with a means to provide feedback as well. Airplane Standard Operating Procedures (SOP) Manual

Conclusion

Standard operating procedures are far more than administrative documents. Viewed through the Swiss Cheese Model, they interface with nearly every defensive layer in aviation safety. They define standards, support sound decision-making and help crews avoid—or recover from—undesired aircraft states.

Given their central role, SOPs deserve deliberate, informed design, thoughtful implementation and a culture that values disciplined compliance. When developed with human factors in mind and applied consistently in the cockpit, SOPs do not diminish professionalism—they enable it.

In aviation, safety is rarely about heroics. More often, it is about doing ordinary things extraordinarily well, as often as humanly possible.