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Attributes | |
ACN | 961946 |
Time | |
Date | 201107 |
Local Time Of Day | 0601-1200 |
Environment | |
Flight Conditions | VMC |
Light | Dawn |
Aircraft 1 | |
Make Model Name | B767-300 and 300 ER |
Operating Under FAR Part | Part 121 |
Flight Phase | Parked |
Flight Plan | IFR |
Component | |
Aircraft Component | Checklists |
Person 1 | |
Function | Captain Pilot Not Flying |
Qualification | Flight Crew Air Transport Pilot (ATP) |
Experience | Flight Crew Last 90 Days 200 Flight Crew Total 21000 Flight Crew Type 8000 |
Events | |
Anomaly | Aircraft Equipment Problem Critical Deviation - Procedural Published Material / Policy |
Narrative:
In reviewing the QRH a couple of safety issues jump out at me. First; the index references checklists by chapter and page number; e.g. 14.4. However; the tabs on the QRH do not have chapter numbers. Therefore; the pilot must flip through chapters in the QRH to locate the correct chapter; and then flip to the correct page. This creates an unnecessary and time consuming step which could easily be remedied by placing the chapter number along with the system title on the QRH tab. Secondly; the index contains little if any cross referencing. If the pilot attempts to look up fuel leak he will find nothing in the index. The checklist is titled engine fuel leak and is only listed under that title. Since a fuel leak could easily be somewhere other than the engine; this seems an illogical title and at the very least should be cross referenced under the more generic term fuel leak. The same is true for the structural damage/controllability checklist. Given the checklist has a split title; and that the two issues are not necessarily related; it should be cross referenced under both structural damage and controllability. There likely are more examples of these issues. Between the inadequate early training and lack of access to the QRH prior to activation; I believe a substantial safety risk exists. Additionally; and along the same lines of inadequate training; I find considerable confusion exists over the new missed approach profile which was implemented by flight manual revision. This is an entirely new profile; implemented with no simulator training; and expected to be performed in a high risk environment near the ground and potentially in very poor weather. Any of these factors singularly could create a serious safety risk; and cumulatively are positively dangerous.
Original NASA ASRS Text
Title: A B767 Captain noted that a newly provided QRH index is organized by Chapter which then references only pages that are not organized by chapter or system for quick reference. He also noted that implementing new complex procedures without simulator training is a new and dangerous precedent.
Narrative: In reviewing the QRH a couple of safety issues jump out at me. First; the index references checklists by chapter and page number; e.g. 14.4. However; the tabs on the QRH do not have chapter numbers. Therefore; the pilot must flip through chapters in the QRH to locate the correct chapter; and then flip to the correct page. This creates an unnecessary and time consuming step which could easily be remedied by placing the chapter number along with the system title on the QRH tab. Secondly; the index contains little if any cross referencing. If the pilot attempts to look up FUEL LEAK he will find nothing in the index. The checklist is titled ENG FUEL LEAK and is only listed under that title. Since a fuel leak could easily be somewhere other than the engine; this seems an illogical title and at the very least should be cross referenced under the more generic term FUEL LEAK. The same is true for the STRUCTURAL DAMAGE/CONTROLLABILITY checklist. Given the checklist has a split title; and that the two issues are not necessarily related; it should be cross referenced under both STRUCTURAL DAMAGE and CONTROLLABILITY. There likely are more examples of these issues. Between the inadequate early training and lack of access to the QRH prior to activation; I believe a substantial safety risk exists. Additionally; and along the same lines of inadequate training; I find considerable confusion exists over the new missed approach profile which was implemented by Flight Manual revision. This is an entirely new profile; implemented with no simulator training; and expected to be performed in a high risk environment near the ground and potentially in very poor weather. Any of these factors singularly could create a serious safety risk; and cumulatively are positively dangerous.
Data retrieved from NASA's ASRS site as of April 2012 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.