37000 Feet | Browse and search NASA's Aviation Safety Reporting System |
|
Attributes | |
ACN | 583231 |
Time | |
Date | 200305 |
Day | Thu |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : den.airport |
State Reference | CO |
Altitude | msl single value : 14000 |
Environment | |
Flight Conditions | VMC |
Light | Daylight |
Aircraft 1 | |
Controlling Facilities | tracon : d01.tracon tower : mmun.tower |
Operator | general aviation : corporate |
Operating Under FAR Part | Part 91 |
Flight Phase | descent : approach |
Route In Use | approach : visual arrival : on vectors |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : corporate |
Function | flight crew : captain oversight : pic |
Qualification | pilot : cfi pilot : atp |
Experience | flight time last 90 days : 100 flight time total : 10000 flight time type : 115 |
ASRS Report | 583231 |
Person 2 | |
Affiliation | company : corporate |
Function | flight crew : first officer |
Events | |
Anomaly | aircraft equipment problem : critical other anomaly other |
Independent Detector | aircraft equipment other aircraft equipment : master caution, accessory door warning other flight crewa other flight crewb |
Resolutory Action | controller : issued advisory controller : provided flight assist controller : issued new clearance flight crew : diverted to another airport none taken : detected after the fact |
Consequence | other |
Supplementary | |
Problem Areas | Aircraft ATC Human Performance |
Primary Problem | Aircraft |
Air Traffic Incident | Intra Facility Coordination Failure other |
Narrative:
After takeoff on runway 35L at den the master caution system began to cycle on/off climbing through 12000 ft on departure. It would not cancel. It was caused by a cycling accessory door warning light. Both pilots understood ATC had cleared our flight for a visual approach to runway 35L after we requested a return to den. We lined up to follow traffic we believed we were supposed to follow and were surprised when the tower informed us we were supposed to land on runway 35R. We did so without further incident. In retrospect I believe the manufacturer provided checklists are at the root of our miscom with ATC. During the 5 mins from the onset of the event to landing we had to visit 7 sections of a physically difficult to use, 3/4 inch thick, booklet style checklist. Its full of non essential verbiage that, during time critical events, increase crew workload and opportunity for error. As an example, it is not intuitive to locate a 'door caution light' by turning to 'tab V-5.' one must first visit an index that goes on and on for pages. The 'gama' checklist format and the verbiage chosen by the manufacturer is best understood if you put yourself in the shoes of the manufacturer's lawyer. Some human factors study of the value of such checklists would be most useful. It would be interesting to see what a credentialed human factors, CRM knowledge group (such as the NASA/university of texas group) would derive from a study of business jet cockpit checklist development.
Original NASA ASRS Text
Title: C560XL CREW NOTES EMER CHKLISTS PROVIDED BY THE ACFT MANUFACTURER ARE DIFFICULT TO USE, DON'T FLOW, AND ARE NOT PLT FRIENDLY TO USE IN AN EMER SIT.
Narrative: AFTER TKOF ON RWY 35L AT DEN THE MASTER CAUTION SYS BEGAN TO CYCLE ON/OFF CLBING THROUGH 12000 FT ON DEP. IT WOULD NOT CANCEL. IT WAS CAUSED BY A CYCLING ACCESSORY DOOR WARNING LIGHT. BOTH PLTS UNDERSTOOD ATC HAD CLRED OUR FLT FOR A VISUAL APCH TO RWY 35L AFTER WE REQUESTED A RETURN TO DEN. WE LINED UP TO FOLLOW TFC WE BELIEVED WE WERE SUPPOSED TO FOLLOW AND WERE SURPRISED WHEN THE TWR INFORMED US WE WERE SUPPOSED TO LAND ON RWY 35R. WE DID SO WITHOUT FURTHER INCIDENT. IN RETROSPECT I BELIEVE THE MANUFACTURER PROVIDED CHKLISTS ARE AT THE ROOT OF OUR MISCOM WITH ATC. DURING THE 5 MINS FROM THE ONSET OF THE EVENT TO LNDG WE HAD TO VISIT 7 SECTIONS OF A PHYSICALLY DIFFICULT TO USE, 3/4 INCH THICK, BOOKLET STYLE CHKLIST. ITS FULL OF NON ESSENTIAL VERBIAGE THAT, DURING TIME CRITICAL EVENTS, INCREASE CREW WORKLOAD AND OPPORTUNITY FOR ERROR. AS AN EXAMPLE, IT IS NOT INTUITIVE TO LOCATE A 'DOOR CAUTION LIGHT' BY TURNING TO 'TAB V-5.' ONE MUST FIRST VISIT AN INDEX THAT GOES ON AND ON FOR PAGES. THE 'GAMA' CHKLIST FORMAT AND THE VERBIAGE CHOSEN BY THE MANUFACTURER IS BEST UNDERSTOOD IF YOU PUT YOURSELF IN THE SHOES OF THE MANUFACTURER'S LAWYER. SOME HUMAN FACTORS STUDY OF THE VALUE OF SUCH CHKLISTS WOULD BE MOST USEFUL. IT WOULD BE INTERESTING TO SEE WHAT A CREDENTIALED HUMAN FACTORS, CRM KNOWLEDGE GROUP (SUCH AS THE NASA/UNIVERSITY OF TEXAS GROUP) WOULD DERIVE FROM A STUDY OF BUSINESS JET COCKPIT CHKLIST DEVELOPMENT.
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.