37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 259574 |
Time | |
Date | 199312 |
Day | Tue |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : sfo |
State Reference | CA |
Altitude | agl bound lower : 0 agl bound upper : 18000 |
Environment | |
Flight Conditions | VMC |
Light | Dusk |
Aircraft 1 | |
Controlling Facilities | tower : sfo tower : sba |
Operator | common carrier : air carrier |
Make Model Name | Medium Large Transport, Low Wing, 2 Turbojet Eng |
Flight Phase | climbout : intermediate altitude climbout : takeoff ground : preflight |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | other pilot : atp pilot : flight engineer pilot : cfi |
Experience | flight time last 90 days : 100 flight time total : 11000 flight time type : 2000 |
ASRS Report | 215957 |
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 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 and medium large transport aircraft. '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 was so preoccupied and 'heads-down' doing the new before takeoff checklist while moving that we missed 2 calls from ground control and bypassed a taxiway that they wanted us to turn on. The checklist is long and there is a lot of verbosity and redundancy in some of the replies. It is particularly hazardous to have pilots checking compass alignment and reading the actual heading while moving, especially at night or in low visibility. Although the final items of the before takeoff checklist are not 'challenge and response', we deviated and did it that way because they are important items that must be verified. During departure, we became very busy and neglected to turn the APU off until 18000 ft, because it is no longer on the after start checklist.
Original NASA ASRS Text
Title: PUB DEFICIENCY RPTED BY AN 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 AND MLG ACFT. '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 WAS SO PREOCCUPIED AND 'HEADS-DOWN' DOING THE NEW BEFORE TKOF CHKLIST WHILE MOVING THAT WE MISSED 2 CALLS FROM GND CTL AND BYPASSED A TXWY THAT THEY WANTED US TO TURN ON. THE CHKLIST IS LONG AND THERE IS A LOT OF VERBOSITY AND REDUNDANCY IN SOME OF THE REPLIES. IT IS PARTICULARLY HAZARDOUS TO HAVE PLTS CHKING COMPASS ALIGNMENT AND READING THE ACTUAL HDG WHILE MOVING, ESPECIALLY AT NIGHT OR IN LOW VISIBILITY. ALTHOUGH THE FINAL ITEMS OF THE BEFORE TKOF CHKLIST ARE NOT 'CHALLENGE AND RESPONSE', WE DEVIATED AND DID IT THAT WAY BECAUSE THEY ARE IMPORTANT ITEMS THAT MUST BE VERIFIED. DURING DEP, WE BECAME VERY BUSY AND NEGLECTED TO TURN THE APU OFF UNTIL 18000 FT, BECAUSE IT IS NO LONGER ON THE AFTER START 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.