37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 1402915 |
Time | |
Date | 201611 |
Place | |
Locale Reference | ZZZ.Airport |
State Reference | US |
Aircraft 1 | |
Make Model Name | Any Unknown or Unlisted Aircraft Manufacturer |
Flight Phase | Parked |
Person 1 | |
Function | Check Pilot Pilot Not Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Events | |
Anomaly | Deviation - Procedural Published Material / Policy |
Narrative:
I just completed giving five line checks to regular line crews one month after we changed our before push and departure plan checklists. Four out of five crews made significant errors with the new checklist. While the addition of runway (and intersection if required) is a great addition to our checklist; I believe we did a poor job managing our risk; especially the human factors portion; in how we made this change. To send out a multi-page bulletin changing arguably our most important checklists; and then four months later say activate it without any training or even review and practice; this bulletin is setting our crews up to fail. Human factors is totally being ignored. When you disrupt a flow; you create turbulence which leads to mistakes. This is especially true for pilots 'flowing' through checklists. Yes; professional pilots should go review and practice on their own; but our pilots had neither time to practice nor given a demonstration of how the new checklist should be conducted. It seems like a simple change but we underestimate how much it really distracts our pilots. Better training. Require a demonstration video be viewed to drive home checklist changes and teach the new procedures. Need for better training for checklist and procedures changes.
Original NASA ASRS Text
Title: Line Check Airman finds that one month after implementation; revised checklists are being properly conducted by only one in five flight crews. He believed that lack of proper training was the main culprit.
Narrative: I just completed giving five line checks to regular Line Crews one month after we changed our Before Push and Departure Plan checklists. Four out of five Crews made significant errors with the new checklist. While the addition of runway (and intersection if required) is a great addition to our checklist; I believe we did a poor job managing our risk; especially the human factors portion; in how we made this change. To send out a multi-page Bulletin changing arguably our most important checklists; and then four months later say activate it without any training or even review and practice; this bulletin is setting our Crews up to fail. Human factors is totally being ignored. When you disrupt a flow; you create turbulence which leads to mistakes. This is especially true for Pilots 'flowing' through checklists. Yes; professional Pilots should go review and practice on their own; but our Pilots had neither time to practice nor given a demonstration of how the new checklist should be conducted. It seems like a simple change but we underestimate how much it really distracts our Pilots. Better training. Require a demonstration video be viewed to drive home checklist changes and teach the new procedures. Need for better training for checklist and procedures changes.
Data retrieved from NASA's ASRS site and automatically converted to unabbreviated mixed upper/lowercase text. This report is for informational purposes with no guarantee of accuracy. See NASA's ASRS site for official report.