NTSB Safety Alert SA-018 - Preventing Rote Callouts

Preventing Rote Callouts

Confirm Cockpit Indications Before Making Callouts

The problem

 National Transportation Safety Board investigations have identified several

instances in which pilots made callouts without first verifying the cockpit indication

that corresponded with the callout .

 In these case s, the pilots acted out of habit and made callouts based on what they

expected to see regarding the cockpit indication but did not take the time to

verify it.

 Examples of accident investigations include the following :

o A Boeing 757 overran the end of the runway while landing in Jackson Hole,

Wyoming. The captain called out “deployed” even though the speedbrakes

were not deployed and “two in reverse” even though neither reverser was

fully deployed. Both the speedbrakes and the thrust reversers had

mechanical defects, and the captain did not manually deploy the

speedbrake s when they failed to deploy automatically because, based on

his rote callout, he did not recognize tha t they did not deploy .1

o A Hawker 800 crashed after a late go -around attempt in Owatonna ,

Minnesota . After touchdown , the copilot called out “we’re dumped ,” but the

flaps were not all the way in the lift dump position and the airplane did not

slow down as expected, leading the pilot to attempt t o go around.2

1 Runway Overrun, American Airlines Flight 2253, Boeing 757 -200, N668AA, Jackson Hole, Wyoming,

December 29, 2010, Aircraft Accident Report NTSB/AAR -12/01 (Washington, DC: National Transportation Safety

Board, 2012) .

2 Crash During Attempted Go -Around After Landing, East Coast Jets Flight 81, Hawker Beechcraft

Corporation 125-800A, N818MV, Owatonna, Minnesota, July 31, 2008, Aircraft Accident Report NTSB/AAR -11/01

(Washingt on, DC: National Transportation Safety Board, 2011) .

SA-018 October 2012 , revised December 2015

o An MD -82 crashed after taking off with the flaps retracted in Madrid, Spain .

The first officer called out the proper flap setting (not the indicated setting) ,

but the flaps were not properly set for takeoff .3

 The rote callouts made in these accidents prevented or delayed the pilots’ proper

response during a critical phase of flight or caused the pilots to think that an

action had been taken when it had not.

 All pilots can be vulnerable to making errant callouts if they become complacent,

which allows habits and expectations to influence their responses. T aking explicit

steps to direct attention, method ically verify the status of a checklist item, and

make callouts using standard phraseology can reduce your chances of making

errors similar to those cited above.

What can pilots do?

 Do not become complacent and respond out of habit when running a checklist.

For every callout , there should be a corresponding indication or setting. Train

yourself to direct your attention on the indicator or display long enough to be sure

of what the indicator is telling you every time . Physically touching a control or

pointing to an indicator can be a useful technique.

 Adopt a methodical pace when reading or responding to checklist items so that

you can ensure that you see and verify each cockpit indication.

 Cross check related indications to see if the aircraft’s performance is changing.

For example, a callout of “flaps fifteen” may be accompanied by a characteristic

change in pitch attitude and airspeed, so know what to expect on the other

instruments, not just the flap position indicator.

 Be attentive to an indicator’s color and do not anticipate a color change before it

occurs . For e xample, a thrust reverse indicator is often amber when reversers are

in transit but green when reversers are fully deployed.

 Make a point of giving and receiving a proper response to checklist callout s.

Improper or nonstandard phraseology, n ods, mumbles , and nonverbal signals are

unacceptable .

 Operational d istractions, such as radio calls, can interrupt or drown out a callout.

Stay focused and assertive and repeat the callout if ne eded . Prevent

nonoperational distractions, such as cockpit conversations, b y implementing a

“sterile cockpit” where callouts are expected.

3 Accident Involving a McDonnell Douglas DC -9-82 (MD -82) Aircraft, Registration EC -HFP Operated by Spanair, at

Madrid -Barajas Airport, on 20 August 2008, Report A -032/2008 (Madrid, Spain: Comisión de Investigatión de

Accidentes e Incidentes de Aviación Civil, 2011) .

SA-018 October 2012 , revised December 2015

 Set an example. If you make your callouts crisp and catch any missed indication s,

your fellow pilot will likely follow suit.

 Awareness is a large part of the solution. Add callout awareness to your preflight

briefings and be ready to verbalize each and every discrepancy.

Need more information?

 Federal Aviation Administration Advisory Circular 120 -71A, “Standard Operating

Procedures for Flight Deck Crewmembers .”