Narrative:

Procedural violation: landed MD80 with ignition switch off in violation of company checklist and afm requirements. Specific conditions: the descent checklist specifies that the ignition will be in 'a' or 'B' (on) 'prior to landing.' as a technique, I normally turn the ignition on when the gear is extended. Thus it is connected with some specific action and ensures the 10 min on limitation is not exceeded. In this instance, the visual approach was complicated by strong winds which required a discussion with my first officer about general confign and where to begin descent. We were also tired as it was early in the morning. As the PNF, it was my job to turn the ignition on and respond 'descent checklist complete.' in the rush of things, I forgot. I should add that this omission has occurred to me numerous times and usually involves anything slightly nonstandard: high approach, rushed final, contacting tower about the time the gear is extended, high density airport, etc. Contributing factors: 1) no backup for checklist initiation. Airline's policy does not utilize the 2 man concept when initiating checklists or in continuing to run them past natural breaks. The aom does not designate who will initiate checklists. As a result, the PNF initiates and completes most checklists. Except when using the mechanical checklist, all checklists are read silently. The PNF is only required to state that the 'descent checklist is complete.' the PF is out of the loop as far as initiating the descent checklist or being aware of its progress. Because the descent checklist is read silently, unless the PF does his own scan, he is not even aware if the other pilot is accomplishing the checklist properly. As a result, if the PNF forgets an item, the PF is not in the loop to correct the omission. This is particularly true for the ignition as the PF is loaded down with flying the aircraft and responding to the before landing checklist and so is not in a position to monitor the progress of the descent checklist. 2) overlapping checklists: the ignition for the former owner aircraft is the last item on the descent checklist and is the only item underneath the title 'prior to landing.' in the case of the ignition, this item is accomplished while the before landing checklist is in progress: 2 checklists are in progress at the same time! As stated above, this occurs because of the time limit on the ignition system. Turning the ignition on at 10000 ft, which is the previous stop point on the descent checklist, would routinely exceed the 10 min time limit. So it must be done this way. Recommendations: 1) change policy and require all checklists (including defined breaks) to be initiated by the PF, or captain as required. This would bring 2 pilots into the process and increase the chances of checklist accomplishment in a high crew workload environment. 2) make clearly defined breaks in checklists and define specific points (altitudes or actions) which will trigger the PF or captain to call for continuation of the checklist. The after takeoff, climb and descent checklists have clearly defined breaks, but the before landing checklist has none and there are at least 3 natural breaks in the flow. I know company feels the mechanical switches solve this problem, but they do not solve the problem of having one pilot remind the other to continue or complete the checklist. 3) require all checklists to be read aloud so that the PF stays in the loop. This helps ensure the items are accomplished, and accomplished correctly. 4) remove 'ignition' from the descent checklist for ex-owner aircraft and place it in the before landing checklist in the time frame where it belongs. Cull out duplication in the before landing checklist to make room for 'ignition,' to say nothing of decreasing crew workload in a high crew workload environment. (Duplication would not be necessary if checklist initiation procedures utilized the 2-MAN concept.) 5) have the PF or captain respond only to critical action items on the before takeoff and before landing checklists. This will reduce his crew workload so he can taxi safely or fly a better approach, as well as monitor checklist accomplishment.

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Original NASA ASRS Text

Title: AN MD82 PIC, PNF, FORGETS TO TURN ON THE INFLT IGNITION WHEN AT THE LOM WHILE ON A VISUAL APCH TO RWY 35L AT OKC, OK.

Narrative: PROCEDURAL VIOLATION: LANDED MD80 WITH IGNITION SWITCH OFF IN VIOLATION OF COMPANY CHKLIST AND AFM REQUIREMENTS. SPECIFIC CONDITIONS: THE DSCNT CHKLIST SPECIFIES THAT THE IGNITION WILL BE IN 'A' OR 'B' (ON) 'PRIOR TO LNDG.' AS A TECHNIQUE, I NORMALLY TURN THE IGNITION ON WHEN THE GEAR IS EXTENDED. THUS IT IS CONNECTED WITH SOME SPECIFIC ACTION AND ENSURES THE 10 MIN ON LIMITATION IS NOT EXCEEDED. IN THIS INSTANCE, THE VISUAL APCH WAS COMPLICATED BY STRONG WINDS WHICH REQUIRED A DISCUSSION WITH MY FO ABOUT GENERAL CONFIGN AND WHERE TO BEGIN DSCNT. WE WERE ALSO TIRED AS IT WAS EARLY IN THE MORNING. AS THE PNF, IT WAS MY JOB TO TURN THE IGNITION ON AND RESPOND 'DSCNT CHKLIST COMPLETE.' IN THE RUSH OF THINGS, I FORGOT. I SHOULD ADD THAT THIS OMISSION HAS OCCURRED TO ME NUMEROUS TIMES AND USUALLY INVOLVES ANYTHING SLIGHTLY NONSTANDARD: HIGH APCH, RUSHED FINAL, CONTACTING TWR ABOUT THE TIME THE GEAR IS EXTENDED, HIGH DENSITY ARPT, ETC. CONTRIBUTING FACTORS: 1) NO BACKUP FOR CHKLIST INITIATION. AIRLINE'S POLICY DOES NOT UTILIZE THE 2 MAN CONCEPT WHEN INITIATING CHKLISTS OR IN CONTINUING TO RUN THEM PAST NATURAL BREAKS. THE AOM DOES NOT DESIGNATE WHO WILL INITIATE CHKLISTS. AS A RESULT, THE PNF INITIATES AND COMPLETES MOST CHKLISTS. EXCEPT WHEN USING THE MECHANICAL CHKLIST, ALL CHKLISTS ARE READ SILENTLY. THE PNF IS ONLY REQUIRED TO STATE THAT THE 'DSCNT CHKLIST IS COMPLETE.' THE PF IS OUT OF THE LOOP AS FAR AS INITIATING THE DSCNT CHKLIST OR BEING AWARE OF ITS PROGRESS. BECAUSE THE DSCNT CHKLIST IS READ SILENTLY, UNLESS THE PF DOES HIS OWN SCAN, HE IS NOT EVEN AWARE IF THE OTHER PLT IS ACCOMPLISHING THE CHKLIST PROPERLY. AS A RESULT, IF THE PNF FORGETS AN ITEM, THE PF IS NOT IN THE LOOP TO CORRECT THE OMISSION. THIS IS PARTICULARLY TRUE FOR THE IGNITION AS THE PF IS LOADED DOWN WITH FLYING THE ACFT AND RESPONDING TO THE BEFORE LNDG CHKLIST AND SO IS NOT IN A POS TO MONITOR THE PROGRESS OF THE DSCNT CHKLIST. 2) OVERLAPPING CHKLISTS: THE IGNITION FOR THE FORMER OWNER ACFT IS THE LAST ITEM ON THE DSCNT CHKLIST AND IS THE ONLY ITEM UNDERNEATH THE TITLE 'PRIOR TO LNDG.' IN THE CASE OF THE IGNITION, THIS ITEM IS ACCOMPLISHED WHILE THE BEFORE LNDG CHKLIST IS IN PROGRESS: 2 CHKLISTS ARE IN PROGRESS AT THE SAME TIME! AS STATED ABOVE, THIS OCCURS BECAUSE OF THE TIME LIMIT ON THE IGNITION SYS. TURNING THE IGNITION ON AT 10000 FT, WHICH IS THE PREVIOUS STOP POINT ON THE DSCNT CHKLIST, WOULD ROUTINELY EXCEED THE 10 MIN TIME LIMIT. SO IT MUST BE DONE THIS WAY. RECOMMENDATIONS: 1) CHANGE POLICY AND REQUIRE ALL CHKLISTS (INCLUDING DEFINED BREAKS) TO BE INITIATED BY THE PF, OR CAPT AS REQUIRED. THIS WOULD BRING 2 PLTS INTO THE PROCESS AND INCREASE THE CHANCES OF CHKLIST ACCOMPLISHMENT IN A HIGH CREW WORKLOAD ENVIRONMENT. 2) MAKE CLRLY DEFINED BREAKS IN CHKLISTS AND DEFINE SPECIFIC POINTS (ALTS OR ACTIONS) WHICH WILL TRIGGER THE PF OR CAPT TO CALL FOR CONTINUATION OF THE CHKLIST. THE AFTER TKOF, CLB AND DSCNT CHKLISTS HAVE CLRLY DEFINED BREAKS, BUT THE BEFORE LNDG CHKLIST HAS NONE AND THERE ARE AT LEAST 3 NATURAL BREAKS IN THE FLOW. I KNOW COMPANY FEELS THE MECHANICAL SWITCHES SOLVE THIS PROB, BUT THEY DO NOT SOLVE THE PROB OF HAVING ONE PLT REMIND THE OTHER TO CONTINUE OR COMPLETE THE CHKLIST. 3) REQUIRE ALL CHKLISTS TO BE READ ALOUD SO THAT THE PF STAYS IN THE LOOP. THIS HELPS ENSURE THE ITEMS ARE ACCOMPLISHED, AND ACCOMPLISHED CORRECTLY. 4) REMOVE 'IGNITION' FROM THE DSCNT CHKLIST FOR EX-OWNER ACFT AND PLACE IT IN THE BEFORE LNDG CHKLIST IN THE TIME FRAME WHERE IT BELONGS. CULL OUT DUPLICATION IN THE BEFORE LNDG CHKLIST TO MAKE ROOM FOR 'IGNITION,' TO SAY NOTHING OF DECREASING CREW WORKLOAD IN A HIGH CREW WORKLOAD ENVIRONMENT. (DUPLICATION WOULD NOT BE NECESSARY IF CHKLIST INITIATION PROCS UTILIZED THE 2-MAN CONCEPT.) 5) HAVE THE PF OR CAPT RESPOND ONLY TO CRITICAL ACTION ITEMS ON THE BEFORE TKOF AND BEFORE LNDG CHKLISTS. THIS WILL REDUCE HIS CREW WORKLOAD SO HE CAN TAXI SAFELY OR FLY A BETTER APCH, AS WELL AS MONITOR CHKLIST ACCOMPLISHMENT.

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.