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|
Attributes | |
ACN | 259572 |
Time | |
Date | 199312 |
Day | Tue |
Local Time Of Day | 0601 To 1200 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tower : pdx |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : takeoff ground : preflight ground other : taxi |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : cfi pilot : atp pilot : flight engineer |
Experience | flight time last 90 days : 100 flight time total : 11000 flight time type : 2000 |
ASRS Report | 259572 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : published procedure non adherence other other anomaly other |
Independent Detector | other flight crewa |
Resolutory Action | none taken : anomaly accepted |
Consequence | Other |
Supplementary | |
Primary Problem | Aircraft |
Air Traffic Incident | Pilot Deviation |
Situations | |
Publication | Unspecified |
Narrative:
On 12/X/93, our airlines instituted new checklists for all aircraft, which consist of widebody transport's - large transport's medium large transport's older '3- holer' large transport's will be at a later date.) the reasons for this drastic re-writing of the checklists are: (1) to expedite taxi from the gate area by eliminating an after start checklist (which is accomplished while stopped) and placing those items on a before takeoff checklist (which is accomplished while moving). (2) to 'standardize' all fleets in order to justify future training program reductions. The result has been a disruption of proven flow patterns and elimination of critical checklist items. Both of us are medium large transport pilots and had not flown for 3 weeks, so we took our time. The before start checklist was very disjointed and difficult to work with. Previous flow patterns and call-outs, which had been developed over several yrs, were disrupted. On the before pushback checklist, the flight attendants were not aware that we now had a new checklist item (cabin preparation) whereby all bags must be stowed before the entry door is closed. However, on the checklist, the 'doors...closed' is before 'cabin preparation...complete'. After starting engines and while taxiing, we attempted to do the before takeoff checklist and found it difficult, if not hazardous, to accomplish while moving. The captain must check items on the overhead (generators, anti-ice, pitot heat) and both pilots must align the compasses with the wet compass and call out the heading - all while moving. We were so confused that we forgot to give the flight attendants the 'prepare for takeoff' announcement. The final items on the before takeoff checklist are not challenge and response, but are done unilaterally by the first officer. The justification is that the captain is busy taxiing; however he was busy taxiing when he was doing the previous items! After takeoff, we neglected to turn on our center tank fuel pumps and turn off the APU, because they were removed from the checklist. On descent, bumpy air alerted us to turn on the seat belt sign, otherwise we may have forgotten it, because it is no longer on the checklist.
Original NASA ASRS Text
Title: PUB DEFICIENCY RPTED BY ACR FO IN CHKLIST DESIGN AND SUBSEQUENT CHKLIST USE.
Narrative: ON 12/X/93, OUR AIRLINES INSTITUTED NEW CHKLISTS FOR ALL ACFT, WHICH CONSIST OF WDB'S - LGT'S MLG'S OLDER '3- HOLER' LGT'S WILL BE AT A LATER DATE.) THE REASONS FOR THIS DRASTIC RE-WRITING OF THE CHKLISTS ARE: (1) TO EXPEDITE TAXI FROM THE GATE AREA BY ELIMINATING AN AFTER START CHKLIST (WHICH IS ACCOMPLISHED WHILE STOPPED) AND PLACING THOSE ITEMS ON A BEFORE TKOF CHKLIST (WHICH IS ACCOMPLISHED WHILE MOVING). (2) TO 'STANDARDIZE' ALL FLEETS IN ORDER TO JUSTIFY FUTURE TRAINING PROGRAM REDUCTIONS. THE RESULT HAS BEEN A DISRUPTION OF PROVEN FLOW PATTERNS AND ELIMINATION OF CRITICAL CHKLIST ITEMS. BOTH OF US ARE MLG PLTS AND HAD NOT FLOWN FOR 3 WKS, SO WE TOOK OUR TIME. THE BEFORE START CHKLIST WAS VERY DISJOINTED AND DIFFICULT TO WORK WITH. PREVIOUS FLOW PATTERNS AND CALL-OUTS, WHICH HAD BEEN DEVELOPED OVER SEVERAL YRS, WERE DISRUPTED. ON THE BEFORE PUSHBACK CHKLIST, THE FLT ATTENDANTS WERE NOT AWARE THAT WE NOW HAD A NEW CHKLIST ITEM (CABIN PREPARATION) WHEREBY ALL BAGS MUST BE STOWED BEFORE THE ENTRY DOOR IS CLOSED. HOWEVER, ON THE CHKLIST, THE 'DOORS...CLOSED' IS BEFORE 'CABIN PREPARATION...COMPLETE'. AFTER STARTING ENGS AND WHILE TAXIING, WE ATTEMPTED TO DO THE BEFORE TKOF CHKLIST AND FOUND IT DIFFICULT, IF NOT HAZARDOUS, TO ACCOMPLISH WHILE MOVING. THE CAPT MUST CHK ITEMS ON THE OVERHEAD (GENERATORS, ANTI-ICE, PITOT HEAT) AND BOTH PLTS MUST ALIGN THE COMPASSES WITH THE WET COMPASS AND CALL OUT THE HDG - ALL WHILE MOVING. WE WERE SO CONFUSED THAT WE FORGOT TO GIVE THE FLT ATTENDANTS THE 'PREPARE FOR TKOF' ANNOUNCEMENT. THE FINAL ITEMS ON THE BEFORE TKOF CHKLIST ARE NOT CHALLENGE AND RESPONSE, BUT ARE DONE UNILATERALLY BY THE FO. THE JUSTIFICATION IS THAT THE CAPT IS BUSY TAXIING; HOWEVER HE WAS BUSY TAXIING WHEN HE WAS DOING THE PREVIOUS ITEMS! AFTER TKOF, WE NEGLECTED TO TURN ON OUR CENTER TANK FUEL PUMPS AND TURN OFF THE APU, BECAUSE THEY WERE REMOVED FROM THE CHKLIST. ON DSCNT, BUMPY AIR ALERTED US TO TURN ON THE SEAT BELT SIGN, OTHERWISE WE MAY HAVE FORGOTTEN IT, BECAUSE IT IS NO LONGER ON THE CHKLIST.
Data retrieved from NASA's ASRS site as of July 2007 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.