Checklist Bloopers

On 30 Oct 1935, Boeing’s Model 299 prototype took off for an evaluation flight by the US Army Air Corps from Wright Field, Dayton, Ohio. At the controls was Major Ployer Hill, test pilot and Chief of Flying at Material Division, Wright Field. Others onboard were co-pilot Lieutenant Donald Leander Putt, Boeing’s Chief Test Pilot Leslie R. Tower and two others.

At stake was a competition to build the military’s next generation long range bomber. Soon after takeoff, the aircraft pitched up, stalled and crashed in a huge fireball. Major Ployer and Leslie Tower died of their injuries.

Investigation revealed that the aircraft crashed because crew had forgotten to remove the flight controls gust locks, thereby locking the elevators at 12.5° that went unnoticed till it was too late. Boeing lost that competition and their Chief Test Pilot. The army would’ve recommended more training to handle complex aircraft but for Maj Ployer who never fit the description of someone who would be found wanting in preparation.

Side view of the Boeing XB-17 (Model 299) in flames. (U.S. Air Force photo)

The Checklist is Born

It was a simple error of omission every human is susceptible to. US Army’s test crew assigned to investigate the crash came up with a simple solution to overcome what was then famously dubbed ‘too much airplane for one man to fly’. Out of the flaming debris of Model 299, the Checklist was ushered into aviation (though it was around in some form or the other, but in various shades of disuse).

Model 299 went on to become the B-17 ‘Flying Fortress’ that allowed US forces to carry out their devastating bombing campaign across Nazi Germany which helped turn the tide of World War II.

Over the next half a century, innumerable checklists were developed to grapple with galloping technology that saw introduction of supersonic passenger planes, Flight Management Systems, fly-by-wire, glass cockpits etc. Aeroplanes became complicated amalgamations of massive number of systems and sub-systems that was impossible to manage through memory. Nobody can say definitively how many accidents were prevented by checklists. But aviation – arguably the safest mode of transport today – owes it in no small measure to the humble checklist.

Checklist Basics

SKYBrary describes checklists as “tools that support flight crew airmanship and memory and ensure that all required actions are performed without omission and in an orderly manner. Checklists (normal and non-normal) are usually bundled in an easy-to-use Quick Reference Handbook (QRH).” Two common types of checklists flight crew are required to use are the ‘challenge-and-response’ checklist and the ‘read-do-verify’ checklist. There is enough wisdom available online and in aviation circles about checklists. You will find many useful references if you scroll down to Notes & References at the end of this article. Another must-read on the subject is renowned US surgeon and MacArthur Fellow Atul Gawande’s book ‘The Checklist Manifesto‘.

Checklist Bloopers

Nobody contests the relevance or importance of checklists today, especially in aviation. Its use and design has evolved scientifically and through Human Factors (HFACS) over the years since 1935. But one thing has also become increasingly evident. Human tendency to deviate from checklists can confound even the best laid plans.

In my time, I have seen wheels-up touchdowns, wrong-deck landings, aeroengines written-off by operating wrong handles or switches, engaging rotors with gust locks or rotor brakes applied, million-dollar laser guided bombs dropped on the wrong target and many spectacular bloopers (many with lives lost). A simple preventive strategy to thousands of such incidents and accidents was the checklist; present in the cockpit but never used like it was meant to be.

Checklist Bullying

I have also seen ‘checklist-bullying’ that was never imagined by those who invented checklists. What’s that, you ask? Instructors insisting on trainees memorizing checklist actions for normal and abnormal procedures; some to an extent where candidates threw in the towel because they couldn’t cope with parroting 30-point bulleted lists. This was wholly avoidable if not completely stupid. Many I know have written exams and ‘Gen Tests’ where we were required to list out checks, procedures and emergency actions. The intentions were always noble but misplaced.

Militaryflying & transition training is unique. There is a lot of emphasis on knowing aircraft systems intimately, and rightly so. But sometimes we carry it too far and set ourselves up incorrectly for the cockpit – insistence on memory recall for non-memory items being one of them.

Logical Flows

For many types of aircraft, a logical flow of checks from left to right, top to bottom etc. may be clearly suitable. There’s nothing wrong with that. A logical flow aids memory. I would use it to complement the checklist, never to replace it.

Those of us who did basic flying training on the Kiran (HJT-16, a twin-seater, single engine jet trainer) would remember our left-to-right checks. However, what was meant to be committed to memory was the correct position of switches and controls so that the scanning eye could check for anomalies. Instead, memorizing complete check lists was turned into an instrument of torture which even claimed some pilots high on motor skills but low on rote memory capacity. The same habits continued downstream when trainees trifurcated to fighters, transports and helicopters. Thankfully, this menace has been curbed to a large extent I am told.

Blindfold Checks

I don’t know who invented this training ‘tool’ but to me it’s a perfect example of good intentions leading to a bad outcome – asking a trainee pilot under blindfold (or with eyes closed) to reach for the correct switches and circuit breakers. The desired training outcome was improving cockpit familiarity to such high levels that hands and eyes reach out for the correct controls through muscle memory.

A cardinal principle of flying is that you NEVER reach out or operate any switches in an aircraft out of muscle memory unless it is designed with the HOTAS or HOCAS concept (Hands on Throttle/Collective & Stick). It is the perfect recipe for unmitigated disaster. Far too many accidents have been caused by what Steve Wilson from the NTSB once described as “doing too much too soon followed very quickly by too little too late”. Please draw your own lessons how soon you want to throw out this practice if any vestige of it still exists in your front line or training squadrons.

Intimate knowledge of the cockpit layout is a must: nobody contests that. But I wouldn’t encourage the ‘fastest finger’ habit unless you are a flying mercenary.

‘Hurry Up & Wait’ Captains

Then there are the pilots who follow checklists but don’t want to carry them out in letter and spirit as they are always under some imaginary ‘hurry up and wait’ spell. If it is ‘read-do-verify’, it must follow that sequence. There isn’t any other way. Neither should you be putting on your maevest or replacing your ENC headphone batteries while responding to a ‘challenge-and-respond’ checklist. Ask for that checklist only after you have gone through all the approved ‘memory items’ (seat belts and flight controls, for instance). Multitasking while doing your checks can lead to undesirable bloopers. If necessary, ‘hold checklist at X’, deal with the interruption and then ask to ‘resume checklist from X’. If need be, go all the way to the top of the list.

Take the first start of the day, for instance. It just takes that extra minute to reflect on the steam gauges, MFD ‘Powerplant’ or EICAS page to see everything is within the normal range and holding that way. Yet we have all seen pilots who pick up the collective lever, call out ‘checked’ or ‘complete’ and merrily lift off as if the checklist was meant for the CVR or safety department. As an analogy, it’s like a surgeon storming into an operating theater and wielding his scalpel without having checked the patient’s vitals. Would you like to be on that operating table? Then why should anybody feel safe in the hands of a ‘hurry up and wait’ Captain?

The situation is far more serious than we think. FAA came out with a Safety Alert for Operators (SAFO 16016 of 15/11/2016) on stabilised hover checks before departure. The culprit in many preventable accidents was found to be missed checklist items. Many accidents happened because the crew missed some indication that wasn’t normal for the phase or showed a worrisome trend. If you miss it before leaving the tarmac or the edge of a deck, chances are it will catch up with you at a more inopportune moment. Please spend that extra minute. Or you can spend a lifetime thinking about it on the ground if you are the ‘we don’t need no education’ type. Of course, when the law catches up with you, your cheeks will blush a bright pink (Floyd, anyone?) 😛

Single-Pilot & High-Speed Aircraft

There are obvious difficulties in handling checklists on high-speed, high-performance aircraft if the only pilot’s hands are busy with stick and throttle. Fighter pilots I spoke to still defend their ‘memorize’ & ‘logical flow’ philosophy. Technology has given us cockpits that grow ‘dark’ as systems assume their normal regime, HUD and multi-function displays that ‘cue’ pilots through ‘prompts’ on MFDs. Their checklists are designed to suit that philosophy.

An IAF Su-30 takes to the air (picture courtesy Indian Air Force website)

An ace fighter pilot who has flown the twin-crew (pilot-WSO, tandem seater) Su-30MKI extensively made this point in a lighter vein: “If you wait for the WSO to say ok, checks after takeoff, undercarriage up…it would probably have fallen off by itself anyway!”. Fair point but it takes nothing away from the fact that such modern fighters have no elaborate checks beyond the capacity of a manoeuvring pilot. Some balance has to be struck between memory items and checklists. One hopes that on beasts like the Su-30MKI, adequate thought has been given to checklist bloopers. Russian helicopters i have flown never came with manufacturer’s checklists or QRH/FRC (Flight Reference Cards). We made them in-house, often without adequate scientific knowledge or HFACS of checklist design.

Military Flying is Special

While commercial flying has a different ethos and purpose, military flying involves being prepared for contingencies that can never be foreseen or covered completely with appropriate checklists. The Su-30MKI, for instance, has an auto-go around mode that precludes a wheels-up landing. But how can one disallow that in a military aircraft that may need to do a low overshoot for display or undertake a belly landing after battle damage? Hence an override for the same has been provided. But remember, not all sorties are a scramble, not every start is on the ORP. If necessary, some unlearning to avoid habit-interference may be in order should you decide to transition into airlines someday. And yes, the Sim instructors have that figured out already!

Remember, the checklist was born out of military aviation. We just need to stick with it.

Formation or Display Flying

Understandably, pilots who have flown or led formation aerobatics teams have a different take on this subject. They have a unique style and purpose. Each manoeuvre is rehearsed thousands of times on the ground. They have to keep their head while pitching synchronously through the skies at half-wingspan. Their ‘checklist manifesto’ may not match my Bell 412 checklist or methodology. A respected colleague who has led the IAF ‘Sarang’ formation helicopter aerobatics team makes a wise point that “the most important attribute of a display team pilot is the ability to lose his/her own identity in the collective identity of the team”. The Pilot Flying (PF) keeps the aircraft in the display box while Pilot Monitoring (PM) carries out minimum essential checks through ‘do-verify’ as appropriate to the phase (and proximity) of flight. I have nothing to add except “with great power comes great responsibility”.

The ‘Act Immediately’ Myth

Then there are few contingencies in which the initial actions cannot brook the delay involved in pulling out an FRC or QRH. Carefully identify what these situations may be for the type you fly. You will be surprised how few there are. There are ‘Land Immediately’, ‘Land ASAP’ and ‘Land as soon as Practical’ situations described in my AW139 rotorcraft flight manual. Yes, there are ‘react’ situations, but I wouldn’t use the term ‘act immediately’ very loosely in an aeroplane.

An engine failure situation on a light single or a sudden decompression on a commercial airliner in cruise for instance requires certain actions to be undertaken from muscle memory. But on most twin/multi-engine aircraft the ‘act immediately’ myth can be misleading. Even ‘Sully’ Sullenberger and Jeff Skiles paused for that infinitesimal moment before ‘reacting’ correctly to multiple bird hits and ‘All Engines Out’ situation on US Airways Flight 1549. Did either crew pull handles or operate switches unilaterally or ‘blindfolded’? Definitely not.

One can rarely if ever do a challenge and response for the ejection sequence on a fighter (reason why I still remember the Kiran Mk 1 ejection sequence after 25 years). It is part muscle memory, part DNA. Having watched the ejection video a thousand times, I still cannot help being amazed at the way my colleague, an ace fighter pilot, pulled the handle on a doomed Sea Harrier microseconds before it crashed at Goa. Now, that’s a ‘memory item’ like no other.

Another poignant anecdote. Lieutenant Giavannoli, an onlooker who rushed to pull out Major Ployer from the Model 299’s debris, died a year later (8th March 1936) when the right wing of his prototype Boeing P-36 fighter came off at Logan Field, near Baltimore, Maryland. That is a catastrophic ‘black swan’ situation for which there can be no checklist.

To be sure, there would be a few exigencies in any flight manual that have a few ‘memory items’.  Even such actions should never be rushed or misdiagnosed. Rest of it follows only as per checklist.

A widely respected flight instructor i knew once observed that his first action in any emergency would be to grab the copilot’s hands so that he or she doesn’t pull out any handles or close switches! Same advice back to you too, Captain!

Differentiate between Checklists and SOP

There is a misnomer that tends to bracket ‘checks & procedures’ like they are one and the same. Consequently, the approach towards dealing with both also tends to be similar. Checklists are meant to ensure that the aircraft is appropriately configured for a particular phase of flight and that people don’t make dumb mistakes by forgetting stuff. It is memory-independent whereas SOPs are meant to achieve the mission safely and repeatedly under a wide variety of conditions. They are detailed and need to be learnt and assimilated before taking to the sky. There cannot be a bulleted list for them because then it loses the flexibility crucial to their purpose. But when you bracket them like they are the same, you are setting up for what happened to Air India Flight 605.

Air India Flight 605 Crash, Bangalore, 1990

14 February 1990 was a Valentine’s Day like no other. An Air India Airbus A320 on approach to Bangalore’s HAL airport in perfect weather conditions crashed on the greens of KGA golf course, just short of the perimeter wall of old HAL airport. About two minutes before the accident that killed 92 pax and crew, the Pilot Flying (PF) asked for the landing checklist. The Check Pilot (CP) taking the PF’s check ride dismissed it saying “Negative. I’ll give you at 1400 feet AGL”. Meanwhile the aircraft continued to descend in ‘idle, open descent’ as an increasingly dangerous ‘mode confusion’ situation was building up (a procedural issue).

About one minute before the crash the PF asked for the landing checklist again which the CP called out and executed unilaterally without any challenge, response or verification, thereby denuding the very purpose of a checklist in a precarious situation. The CP would have been better off finishing the pre-landing checklist at an appropriate time so he could pick up & correct the faulty procedure that was being flown. But a deadly mix of two mistakes led to the aircraft crashing short of the intended touchdown point.

The Last Word & Final Memory Item!

Pulling out the FRC or QRH is not a slur. It is the way.

I have seen slow starters withering under ‘checklist bullying’ and trainees being put up for suspension of training because “he cant even remember checks & procedures”. This is a marked departure from what checklists were intended for and must stop immediately.

It is time to rephrase an old line from training academies. Replace “PYFO: Pull your Finger Out” with “Pull Your FRC Out”.

But if you want to be Rhinestone Cowboy who knows ”every crack in these dirty sidewalls of Broadway”, be prepared for “getting cards and letters from people I don’t even know” – DGCA & FAA included! And all of it may not be music to your ears 😉

And please don’t quote Sully here. That departure from checklist where he first started the APU saved Flight 1549 by ensuring electrical power was not lost. But he is Sully. Not everyone wears the aircraft on their shoulder. Most everybody just straps in.

So be honest. And PYFO. Even if it is a ‘sullied’ one, it’s your only hope to avoid checklist bloopers.

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©KP Sanjeev Kumar, 2018. All rights reserved. Cover photo courtesy US Air Force Museum.

Caution: This advice is generic in nature and does not in any way intend to override approved manuals or cover all situations that may be encountered in flying. Please diligently follow the approved type-specific Flight Crew Operating Manual, Rotorcraft Flight Manual, Company SOPs and other checklists appropriate to your aircraft type. Views are personal. Do write to me at kipsake1@gmail.com. Happy landings!

Notes & References

  1. Cockpit Checklists: Concepts, Design and Use. A paper based on NASA Contractor Report No. 177549 by the authors Asaf Degani & Earl Wiener,
  2. The Checklist Manifesto: How to get things right’, by Atul Gawande
  3. Checklists: Purpose and Use, Courtesy SKYbrary
  4. ://www.skybrary.aero/index.php/Checklists_-_Purpose_and_Use
  5. Back to Basics: Checklists in Aviation & Healthcare, Robyn Clay-Williams & Lacy Colligan, May 2015
  6. Flight Safety Foundation ALAR Briefing Note 1.5 via SKYbrary
  7. FSF ALAR Briefing Note 1.3 Golden Rules, via SKYbrary
  8. Lessons we can learn from aviation checklists, www.blog.safetyculture.com
  9. Article on checklists from Aviation Week Network, read it here.
  10. The Checklist Manifesto: A review and application for developers, Robert Roscam via Medium.com
  11. The Perils of Multitasking, William R Klemm, PhD via Psychology Today
  12. Deadly Omissions‘, a cover story by Alan Dean & Shawn Pruchnicki via www.flightsafety.org
  13. Multicultural CRM‘ by David M Bjellos, 2012 via FSF
  14. An analysis by FSF on crash of Air India Flight 605 (with CVR transcript)
  15. Making a List, Checking it Off‘, via www.artoftroubleshooting.com
  16. Civil Aviation Safety Alert Bulletin of PNG 02/2017 on stabilised hover checks before departure
  17. FAA SAFO 16016 dated 15 Nov 2016 on helicopter stabilised hover checks before departure
  18. This Day in Aviation: 30 Oct 1935 (The crash of Model 299)

 

8 thoughts on “Checklist Bloopers

  1. KP so nicely written! I think many youngsters will do well to hoist the difference between SOP and check lists…fly safe..

  2. KP very well explained. There is no denying that checklists are important and required not only in flying but in other facets of life. But one should also understand that they are meant to assist and not become pressure point and fear factor. As always bravo

  3. Excellent post which is well needed. I do not agrra with your observation that Russian aircraft do not have manufacturer approved checklists, though!

    I have noticed a general averseness on the use of checklists in India. It’s not only the pilots I refer to but everyone in this field. Be it engineering, ATC or safe services. It probably is ingrained – we as a nation are just not used to follow directions or rules and a checklist in effect is just that!

    Well written!

    1. My experience with the Russian Kamovs is in-house checklist development. Maybe you had a better checklist experience! Oh, yes…checklists are like an exercise in public discipline; either everyone follows it or it’s no good.

  4. Hi KPS. As usual a highly professional stuff and important one too. The fixed wing guys have custom made cheklist as the fleet has almost common retrofit in aircrafts provided by manufavturer. However the helicopters having varied retrofits dont have custom made check list by manufacturer. They have in RFM one common check list and then few checks in supplements which is left on user to fuse them. Example…in Radar supplement under Normal procedure for Post start check says…in addition to normal checks…carry out…A B C D. But it doesnt say where to incorporate it in main checklist. They leave it on user..who is not qualified to do so and leads to variance in check list with same retrofit.

  5. Hi Sir, briskly and aptly written, as usual. Have always wondered who would be safer.. The ‘hands on throttle-and-stick-pilot’ or the ‘check-list-pilot’. While checklists have always been part of the fail safe approach, react emergencies do require a well thought out strategy, before reaching for the FRC. My ex Air Force instructor stressed on knowing what to do when to do. Though rote memory can be harmful in stressful situations, fatal too, if incorrectly applied, single cockpit ship pilots have little other options. Multi engine crew also have the option of the co-pilot giving corrective inputs.

    Advantage.. Checklist!

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