...checklists and human factors...breakaway thread

[MikeD]

This is critical, I think the term, "immediate action items," or something like that is somewhat misleading, think then do is probably the best idea.

Not misleading at all. We're taught to think then do; and it's even covered in the Dash-1 itself says to even do only those steps necessary to contain the emergency. It's not a problem with the term, it's a problem with guys rushing an EP when they don't need to, and that stems from any number of issues.

 

[Orange Anchor]

Re: Combinations of RPM & Manifold Pressure

That's what the Human Factors discipline addresses. It may require a change in the task to reduce the likelihood of mistakes, or it may require a change in technology (stick shakers, pushers, GPWS, TCAS, etc) or a prohibition on certain error prone activities, such as circling approaches at night.

(Real world in most industries is that the mistake-maker just gets bitched at by the boss and the boss walks away thinking that he's taken care of the problem. )

We did away with NDBs and circling long before I retired. Not worth it but that was based on risk, not error. We also changed so that ALL non-precisions were flown on autopilot to reduce workload.

And yes, most organizations (and for a large part, our country) have never heard of Reason, never heard of how errors evolve and remain in a 'blame culture'.

 

[Orange Anchor]

Some general observations about checklists over the years in GA.

4. I have not figured out the exact number, but if an in flight checklist item has more than about 6 individual tasks and is done in anything other than cruise, the items either won't be done or there is a higher likelihood the pilot will think they performed an item but did not.

That is why many operators have moved as much as possible to the before start checklist. Once the airplane begins moving there are only a very few items to accomplish. The focus is then on taxiing which is not a simple task at big airports and on reaching the runway there are maybe 2-3 items to accomplish before pushing up the power. ALMOST ALL briefings (takeoff, departure, emerg, etc) are done before engine start.

 

[tgrayson]

Re: Combinations of RPM & Manifold Pressure

Not worth it but that was based on risk, not error.

The difference being.....?

 

[Dugie8]

Re: Combinations of RPM & Manifold Pressure

The difference being.....?

Risk is a "known" quantity, error, by a pure definition, is unknown, ie in a perfect world no one sets out to purposely make an error.

Risk can be eliminated, errors happen because we are human.

 

[derg]

Re: Combinations of RPM & Manifold Pressure

My company uses flows and checklists, rather than do lists.

Abnormals are very limited memory actions and then the QRH as a do list.

There are only a couple of memory items. 90% of them "Oxygen masks - ON" but that's pretty obvious. Or turning off the autothrottle arm switch during an engine failure.

 

[Orange Anchor]

Re: Combinations of RPM & Manifold Pressure

The difference being.....?

A study was done in the 80s as I remember by a fellow named Khatwa. He found that the average airline pilot shot maybe 2 NDBs per year.. at the six month sim checks. Few shot actual NDBs so the level of proficiency and currency was an issue. The next thing was that many if not most Non-precisions have step downs and it is easy to confuse those step downs. So, the first thing was to reduce the risk and the second was knowing that due to lack of proficiency there may be errors.

The next step was to require all NPAs to be done on autopilot. There used to be a VOR app to CLT with FML as the VOR. The FAF was about 6 miles north of the VOR and more than a few times I watched guys descend to MDA after crossing the VOR. What FUN!!! I would let them get to MDA, freeze the sim and go VFR with the wx. The airport was NOWHERE in sight. usually it scared the bejusus out of them and they would think they had busted the ride. NO. Instead it was a 'great mistake', one of those mistakes that scares the hell out of you but comes with no consequence other than a strained sphinctor.

All this to say the environment was ripe with risk and left little room for error.

 

[Orange Anchor]

Re: Combinations of RPM & Manifold Pressure

My company uses flows and checklists, rather than do lists.

Abnormals are very limited memory actions and then the QRH as a do list.

There are only a couple of memory items. 90% of them "Oxygen masks - ON" but that's pretty obvious. Or turning off the autothrottle arm switch during an engine failure.

Finally someone listened to the crew that said, "I have to memorize something I have to do maybe once a year and read things I do five or six times a day."

As mentioned, in recips, yes there are some things that need to be done quickly but time and time again we see where crews rushed to do something, missed steps, got them out of order and often compounded the problem. But old school still has influence in some places and since 'we did it this way for years' is the rule, memory items remain.

I never saw it reach completion but did see a few crews rushing to shut down an engine come close to pulling the fire handle on one engine and shutting the start lever on the other one as they hastily went through the drill.