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|
Attributes | |
ACN | 259573 |
Time | |
Date | 199312 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : pdx |
State Reference | OR |
Altitude | agl bound lower : 0 agl bound upper : 0 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
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 | other pilot : flight engineer pilot : cfi pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 11000 flight time type : 2000 |
ASRS Report | 259573 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
Events | |
Anomaly | non adherence : published procedure non adherence : far non adherence : clearance |
Independent Detector | other controllera 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. This medium large transport crew stumbled through the before start checklist and were very uncomfortable with the disrupted flow and the different, disjointed callouts. Flight attendants were not aware of the new item on the checklist 'cabin preparation...complete', where all bags must be stowed and all bins closed prior to closing the entry door. This resulted in delay and confusion at the gate. Because of the short taxi distance to runway 10L at pdx, we were very busy trying to decipher the new before takeoff checklist. We forgot to turn the anti-ice on prior to taxi, because we no longer had an after start checklist to remind us. We missed a call from ground control while doing this lengthy checklist and forgot to switch to tower. We delayed taking the runway in order to run through this entire checklist while stopped. When cleared for takeoff, we held the runway for 30 seconds to accomplish the final items of the before takeoff checklist. Although the new checklist has the first officer doing these items without verification from the captain, we elected to 'modify' it and do a 'challenge and response.' on the majority of flts, crews are forgetting to turn off the APU after takeoff. (It is necessary to wait 1 min after removing air load to turn it off.) on this airplane, somebody had written 'APU' on the after takeoff checklist. This reminded us to turn it off. 'APU' used to be on the old 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. THIS MLG CREW STUMBLED THROUGH THE BEFORE START CHKLIST AND WERE VERY UNCOMFORTABLE WITH THE DISRUPTED FLOW AND THE DIFFERENT, DISJOINTED CALLOUTS. FLT ATTENDANTS WERE NOT AWARE OF THE NEW ITEM ON THE CHKLIST 'CABIN PREPARATION...COMPLETE', WHERE ALL BAGS MUST BE STOWED AND ALL BINS CLOSED PRIOR TO CLOSING THE ENTRY DOOR. THIS RESULTED IN DELAY AND CONFUSION AT THE GATE. BECAUSE OF THE SHORT TAXI DISTANCE TO RWY 10L AT PDX, WE WERE VERY BUSY TRYING TO DECIPHER THE NEW BEFORE TKOF CHKLIST. WE FORGOT TO TURN THE ANTI-ICE ON PRIOR TO TAXI, BECAUSE WE NO LONGER HAD AN AFTER START CHKLIST TO REMIND US. WE MISSED A CALL FROM GND CTL WHILE DOING THIS LENGTHY CHKLIST AND FORGOT TO SWITCH TO TWR. WE DELAYED TAKING THE RWY IN ORDER TO RUN THROUGH THIS ENTIRE CHKLIST WHILE STOPPED. WHEN CLRED FOR TKOF, WE HELD THE RWY FOR 30 SECONDS TO ACCOMPLISH THE FINAL ITEMS OF THE BEFORE TKOF CHKLIST. ALTHOUGH THE NEW CHKLIST HAS THE FO DOING THESE ITEMS WITHOUT VERIFICATION FROM THE CAPT, WE ELECTED TO 'MODIFY' IT AND DO A 'CHALLENGE AND RESPONSE.' ON THE MAJORITY OF FLTS, CREWS ARE FORGETTING TO TURN OFF THE APU AFTER TKOF. (IT IS NECESSARY TO WAIT 1 MIN AFTER REMOVING AIR LOAD TO TURN IT OFF.) ON THIS AIRPLANE, SOMEBODY HAD WRITTEN 'APU' ON THE AFTER TKOF CHKLIST. THIS REMINDED US TO TURN IT OFF. 'APU' USED TO BE ON THE OLD 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.