When the Flight Manual and Line Operations Don't Match

“I Do Everything SOP, Except…”

One missed callout is a slip. The same miss flight after flight is telling you something else.

When I give a line check, I’m looking for the things you’d expect. Is this a competent pilot? Do they communicate well and use good CRM? Do they have good situational awareness? Do they know their airplane and how to operate it most effectively? That isn’t the complete list of must-haves, but it’s a good start.

Some of what stands out on a line check is small. A nonstandard callout. A callout that never gets made. If it’s a one-time miss, that’s not a big deal. Everyone misses one now and then.

When It Happens Every Flight

What makes me curious is seeing the same missed calls flight after flight, in what looks like direct opposition to the Flight Manual. At that point it isn’t a slip anymore. It’s a pattern, and I want to understand why it’s happening.

Why Crews Drift

Sometimes it’s as simple as the pilot not liking that particular callout or procedure. Sometimes it’s complacency. And sometimes the procedure itself is the problem. It’s too complicated to accomplish correctly, or it can’t be done in the time the phase of flight actually allows. Crews find a way that works, and that way becomes the way it’s done.

Normalization of Deviance

I still hear it in briefings today. The Captain says, “I do everything SOP, except…” and then lists all the things he doesn’t do by the book. It might get a quiet chuckle, but he usually means it. This is normalization of deviance. The noncompliance becomes normal, and no one thinks anything is wrong. That’s just the way they do things.

Here’s a common one. Before pushback, the first officer does a flow that turns on the hydraulic pumps, the fuel pumps, and a few other items. That flow has three triggers. The preflight briefing has to be complete. The preflight checklist has to be read and complete. And the gate agent has to come up and hand the Captain the final paperwork.

Many times, I’ll see first officers start the flow the moment the agent walks up, whether the briefing and the checklist are done or not. The agent is the visible cue, so the agent becomes the trigger. It’s common, but it isn’t the correct procedure. All three things have to be done, not just the last one.

But that’s how it works. The procedure on the page and the procedure on the line have quietly become two different things, and nobody ever decided that on purpose.

The Debrief

After the flight, the crew debriefs me first. Maybe they know what they missed and it’s time to confess. Or maybe they don’t think they did anything wrong at all. Either way, I learn a lot from hearing it in their words before I say anything.

Then I debrief them. Sometimes I’m just confirming what they’ve already told me. Other times I’m pointing out what they missed, and often I’ll have them pull out their own manual and read the procedure themselves. It lands differently when they read it than when I tell them.

Where It Goes From There

One crew on one flight is a debrief. The same error showing up over and over is data, and a mature SMS program runs on data. When a deviation keeps coming up, it gets flagged. It might then become a module in online training, or a checking item in the simulator for every pilot on that fleet. The 787 has different errors than the 737, and that’s where the data comes in. Recurrent usually runs on about a nine month cycle, so every pilot on the fleet who comes through in that cycle gets it. The next cycle, the focus is on something else. The data drives the training in each cycle, at least the part that goes beyond what the FAA requires.

Why It Matters

When something goes wrong, the first thing anyone does is read the manual and then compare that to what the crew did. If those two don’t match, the gap becomes the story. Either the procedure was wrong, or the operation wasn’t following its own procedures. Neither is an answer anyone wants to be giving after the fact.

So the question isn’t just whether your crews are following the manual. It’s also whether your manual can be followed.