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Attributes | |
ACN | 774655 |
Time | |
Date | 200802 |
Local Time Of Day | 1201 To 1800 |
Place | |
Locale Reference | airport : zzz.airport |
State Reference | US |
Aircraft 1 | |
Controlling Facilities | tower : zzz.tower |
Operator | common carrier : air carrier |
Make Model Name | Q400 (Formerly Dash 8-400) |
Operating Under FAR Part | Part 121 |
Flight Phase | climbout : takeoff |
Flight Plan | IFR |
Person 1 | |
Affiliation | company : air carrier |
Function | flight crew : first officer |
Qualification | pilot : commercial |
ASRS Report | 774655 |
Person 2 | |
Affiliation | company : air carrier |
Function | flight crew : captain oversight : pic |
Qualification | pilot : atp |
ASRS Report | 774656 |
Events | |
Anomaly | aircraft equipment problem : less severe non adherence : published procedure non adherence : company policies |
Independent Detector | other flight crewa other flight crewb |
Resolutory Action | flight crew : overcame equipment problem |
Consequence | other |
Supplementary | |
Problem Areas | Company Aircraft Chart Or Publication |
Primary Problem | Aircraft |
Narrative:
On takeoff out of ZZZ1 upon gear retraction; first officer noticed both main landing gear door amber lights were illuminated. The captain called for the 'landing gear door malfunction' checklist. The first officer went to the emergency checklist index and proceeded to run the 'landing gear door malfunction checklist.' upon completion of the checklist the malfunction was resolved with no further action required as per checklist. On takeoff out of ZZZ2 upon gear retraction; the captain noticed that the left main gear amber light remained illuminated. The checklist was run again. Once again resolving the problem at that time. We advised maintenance control that maintenance was required upon reaching ZZZ3. After landing in ZZZ3 we reviewed the situation and it was determined that there are in fact 2 checklists both titled 'landing gear door malfunction checklist.' one in white and one in blue print. We had in fact run the one in white as per the index. In a phone conversation with the duty officer at the time; we discussed the situation. We believe that the event occurred as a result of the following; a very busy phase of flight leveling off; changing controllers and heading; with a relatively new first officer; first leg of day. These were all contributing factors to misidenting 1 of 2 checklists with the exact same title. I believe it would be very helpful and much less confusing if in the emergency checklist there was only 1 checklist. By that we mean if a new checklist or procedure is added; the old one needs to be removed to avoid the possibility of running the wrong procedure.
Original NASA ASRS Text
Title: A DH8-Q400 EMER CHECKLIST CONTAINS 2 'LANDING GEAR DOOR MALFUNCTION' PROCEDURES. THE INCORRECT CHECKLIST WAS RUN BY THIS CREW.
Narrative: ON TKOF OUT OF ZZZ1 UPON GEAR RETRACTION; FO NOTICED BOTH MAIN LNDG GEAR DOOR AMBER LIGHTS WERE ILLUMINATED. THE CAPT CALLED FOR THE 'LNDG GEAR DOOR MALFUNCTION' CHKLIST. THE FO WENT TO THE EMER CHKLIST INDEX AND PROCEEDED TO RUN THE 'LNDG GEAR DOOR MALFUNCTION CHKLIST.' UPON COMPLETION OF THE CHKLIST THE MALFUNCTION WAS RESOLVED WITH NO FURTHER ACTION REQUIRED AS PER CHKLIST. ON TKOF OUT OF ZZZ2 UPON GEAR RETRACTION; THE CAPT NOTICED THAT THE L MAIN GEAR AMBER LIGHT REMAINED ILLUMINATED. THE CHKLIST WAS RUN AGAIN. ONCE AGAIN RESOLVING THE PROB AT THAT TIME. WE ADVISED MAINT CTL THAT MAINT WAS REQUIRED UPON REACHING ZZZ3. AFTER LNDG IN ZZZ3 WE REVIEWED THE SITUATION AND IT WAS DETERMINED THAT THERE ARE IN FACT 2 CHKLISTS BOTH TITLED 'LNDG GEAR DOOR MALFUNCTION CHKLIST.' ONE IN WHITE AND ONE IN BLUE PRINT. WE HAD IN FACT RUN THE ONE IN WHITE AS PER THE INDEX. IN A PHONE CONVERSATION WITH THE DUTY OFFICER AT THE TIME; WE DISCUSSED THE SITUATION. WE BELIEVE THAT THE EVENT OCCURRED AS A RESULT OF THE FOLLOWING; A VERY BUSY PHASE OF FLT LEVELING OFF; CHANGING CTLRS AND HDG; WITH A RELATIVELY NEW FO; FIRST LEG OF DAY. THESE WERE ALL CONTRIBUTING FACTORS TO MISIDENTING 1 OF 2 CHKLISTS WITH THE EXACT SAME TITLE. I BELIEVE IT WOULD BE VERY HELPFUL AND MUCH LESS CONFUSING IF IN THE EMER CHKLIST THERE WAS ONLY 1 CHKLIST. BY THAT WE MEAN IF A NEW CHKLIST OR PROC IS ADDED; THE OLD ONE NEEDS TO BE REMOVED TO AVOID THE POSSIBILITY OF RUNNING THE WRONG PROC.
Data retrieved from NASA's ASRS site as of May 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.