899 crew errors observed on 60 flights

[TangoWhiskey]

NASA's Flight Cognition Lab just published this interesting presentation on Checklists, Monitoring, and Multitasking in Cockpit Operations.

https://www.faasafety.gov/files/notices/2008/Oct/Checklists_and_Monitoring_2.pdf

Observing 60 commercial two-crew flights, they found 899 deviations from SOP.

The results of this study--how to modify your use of checklists and flows to prevent errors--are worth review by all pilots.

 

[tonycondon]

i went through that presentation last night. very interesting and some good reminders for all of us in there.

 

[TMetzinger]

I found it interesting too, especially on the errors that crept in when the checklist was used as a "do" list.

 

[sba55]

I found it interesting too, especially on the errors that crept in when the checklist was used as a "do" list.

That's a really important point.

When I learned how to fly, we used those CheckMate or similar checklists. They shouldn't call them checklist - they're way too detailed, and most of the items they 'check' aren't necessary items at all.

 

[Teller1900]

Very interesting indeed, and stuff I think all pilots who routinely work in a multi-crew environment can identify with.

 

[Ted]

Definitely interesting. It seemed like a large number of the errors revolved around checklists that were either poorly written, or the pilot was complacent "knowing" the answer before asking the question.

Thanks for sharing, Troy.

 

[KennyFlys]

i went through that presentation last night. very interesting and some good reminders for all of us in there.

It had me thinking as I read the issue on flows. I teach flows for efficiency, particularly with emergency procedures. But, verify it with a written checklist in non-emergencies in if time allows during emergencies.

 

[Everskyward]

Definitely interesting. It seemed like a large number of the errors revolved around checklists that were either poorly written, or the pilot was complacent "knowing" the answer before asking the question.

I think some checklists get carried away in the interest of CYA. The taxi checklist in the CE-680 starts out with:

1. Exterior lights -- AS REQUIRED
2. Brakes -- APPLY/HOLD
3. PARK BRAKE Handle -- RELEASE

DOH! The whole checklist is like that. It even tells you to release the brakes before you take off... and to use them after landing.

 

[sba55]

I think some checklists get carried away in the interest of CYA. The taxi checklist in the CE-680 starts out with:

1. Exterior lights -- AS REQUIRED
2. Brakes -- APPLY/HOLD
3. PARK BRAKE Handle -- RELEASE

DOH! The whole checklist is like that. It even tells you to release the brakes before you take off... and to use them after landing.

Yeah, which is why I think making a personal checklist for any reasonably complex plane, if allowed, is very useful. The manufacturer lists aren't checklists, they're abbreviated manuals.

On the other side of the coin, those checklists avoid things that actually should be checked. For example, there's an emergency gear extension handle on my plane that needs to be disengaged. Good thing to check, but it's nowhere to be found in the CheckMate, ABS, or Beechcraft checklists.

-Felix

 

[mikea]

I think some checklists get carried away in the interest of CYA. The taxi checklist in the CE-680 starts out with:

1. Exterior lights -- AS REQUIRED
2. Brakes -- APPLY/HOLD
3. PARK BRAKE Handle -- RELEASE

DOH! The whole checklist is like that. It even tells you to release the brakes before you take off... and to use them after landing.

AFTER TAKEOFF

17. Yoke --- LEFT/RIGHT AS REQUIRED

 

[TangoWhiskey]

AFTER TAKEOFF

17. Yoke --- LEFT/RIGHT AS REQUIRED

LOL... shouldn't step 1 be "Pick up Checklist"? And if the last step isn't "Put it away", how are you supposed to know to do so?

 

[Teller1900]

I think some checklists get carried away in the interest of CYA. The taxi checklist in the CE-680 starts out with:

1. Exterior lights -- AS REQUIRED
2. Brakes -- APPLY/HOLD
3. PARK BRAKE Handle -- RELEASE

DOH! The whole checklist is like that. It even tells you to release the brakes before you take off... and to use them after landing.

Funny you should mention absurd checklists items.

Back when my company was mostly 1900C models, there basically weren't any checklists. Even with the introduction of the D model, they checklists were just one page, mostly handwritten, and hardly ever used - certainly not standardized. Then came the Saab 340s, and the FAA mandated checklist usage. So, they wrote checklists for the Saab, then slightly modified them for use in the Beech. Which is why, in our Before Start checklist, we have the line "Cabin Signs -- As Req'd." The only problem is, the 1900 doesn't have cabin signs (seat belt/no smoking). Our "cabin signs" are glow in the dark stickers over every seat. Never the less, we still have to give a response to that item every time we run the checklist.

There are a few other examples, but that was one of my favorites. That, and the fact that the Beech's "Engine Start Checklist" is actually just a flow...Beacons on, door lights out/noted, avionics master off, clear on 1/2 - turning 1/2.

 

[Teller1900]

LOL... shouldn't step 1 be "Pick up Checklist"? And if the last step isn't "Put it away", how are you supposed to know to do so?

"Pick up checklist" would have to be a flow, or else you'd never get to that point! Of course, that would also require any two people to put the checklist in the same place, which NEVER seems to happen.