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A B747-400 crew reports running an incorrect irregular checklist while fatigued because both checklists appeared on the same page with similar names.
| Attributes | |
| ACN | 756457 |
| Time | |
| Date | 200710 |
| Local Time Of Day | 0001 To 0600 |
| Place | |
| Locale Reference | airport : zzzz.airport |
| State Reference | FO |
| Altitude | msl single value : 39000 |
| Aircraft 1 | |
| Controlling Facilities | artcc : zzzz.artcc |
| Operator | common carrier : air carrier |
| Make Model Name | B747-400 |
| Operating Under FAR Part | Part 121 |
| Flight Phase | cruise : level |
| Flight Plan | IFR |
| Person 1 | |
| Affiliation | company : air carrier |
| Function | flight crew : relief pilot |
| Experience | flight time last 90 days : 240 flight time total : 16000 flight time type : 600 |
| ASRS Report | 756457 |
| Person 2 | |
| Affiliation | company : air carrier |
| Function | flight crew : relief pilot |
| Experience | flight time last 90 days : 225 flight time total : 8000 flight time type : 3200 |
| ASRS Report | 756462 |
| Events | |
| Anomaly | aircraft equipment problem : less severe non adherence : published procedure |
| Independent Detector | aircraft equipment other aircraft equipment : eicas other flight crewa other flight crewb |
| Resolutory Action | flight crew : overcame equipment problem |
| Supplementary | |
| Problem Areas | Flight Crew Human Performance Aircraft Chart Or Publication |
| Primary Problem | Flight Crew Human Performance |
Narrative:
EICAS message 'elec bus isln 4' occurred in cruise. PNF looked up irregular procedures table of contents page X which directed him to page Y. PNF accidentally started running 'elec AC bus 4' checklist. After initiating checklist; PNF realized mistake and ran the correct checklist (elec bus isln 4). Human factors were pilot fatigue; and the checklist format. Page Y has both the 'elec AC bus' and 'elec bus isln' on the same page in the flight manual. On page Y both checklist titles are similar and the 'elec AC bus' checklist was more prominent on the page. The outcome was good because both of us saw how fatigue could affect something as easy as running a checklist. We both learned from it.
Original NASA ASRS Text
Title: A B747-400 CREW REPORTS RUNNING AN INCORRECT IRREGULAR CHKLIST WHILE FATIGUED BECAUSE BOTH CHKLISTS APPEARED ON THE SAME PAGE WITH SIMILAR NAMES.
Narrative: EICAS MESSAGE 'ELEC BUS ISLN 4' OCCURRED IN CRUISE. PNF LOOKED UP IRREGULAR PROCS TABLE OF CONTENTS PAGE X WHICH DIRECTED HIM TO PAGE Y. PNF ACCIDENTALLY STARTED RUNNING 'ELEC AC BUS 4' CHKLIST. AFTER INITIATING CHKLIST; PNF REALIZED MISTAKE AND RAN THE CORRECT CHKLIST (ELEC BUS ISLN 4). HUMAN FACTORS WERE PLT FATIGUE; AND THE CHKLIST FORMAT. PAGE Y HAS BOTH THE 'ELEC AC BUS' AND 'ELEC BUS ISLN' ON THE SAME PAGE IN THE FLT MANUAL. ON PAGE Y BOTH CHKLIST TITLES ARE SIMILAR AND THE 'ELEC AC BUS' CHKLIST WAS MORE PROMINENT ON THE PAGE. THE OUTCOME WAS GOOD BECAUSE BOTH OF US SAW HOW FATIGUE COULD AFFECT SOMETHING AS EASY AS RUNNING A CHKLIST. WE BOTH LEARNED FROM IT.
Data retrieved from NASA's ASRS site as of January 2009 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.