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General Aviation Pilots 637
Controllers 39
Cabin/Mechanics/Military/Other 140
TOTAL 2953
ASRS Recently Issued Alerts On…
MD80 galley fire incident
Western U.S. airport SID chart confusion
Western U.S. airport baggage loading procedure
B737-200 loss of primary altimeter & airspeed indicators
Southern U.S. airport hold short line markings
An FAA review of National Transportation
Safety Board (NTSB) accident data
revealed that during the period 1983 to
1993, approximately 279 aircraft accidents
occurred in which a checklist was
improperly used or not used.
A review of ASRS “checklist” related reports for 2003
suggests that many of the same errors identified by the
FAA and NTSB continue to be reported. The most common
checklist errors include the following:
1. Failure to use a checklist.
2. Use of the wrong checklist.
3. Checklist flow interrupted.
4. Checklist item(s) overlooked.
Recent examples of these errors are detailed in the
following ASRS reports:
Checklist Checkup
Interrupted Checklist
■ Everything felt okay until just after touchdown. I veered
to the right…and I was unable to correct. I continued off
the runway, and skidded into the dirt…. After coming to a
stop, I brought the plane back onto the runway…. I
decided…just to takeoff and get out of there as quickly as
possible..... I did not look at my checklist as I always do.
At takeoff speed I began to rotate but the plane did not
seem to respond. My attention diverted and I again drifted
to the right. Nearing the end of the runway, I hit the
brakes hard and skidded to the left off the runway and
down an embankment...
Instead of taking a breath and following normal procedure
after the near crash landing, I was worried what others
would think and I tried to depart the area as quickly as
possible. Upon inspection of the plane the trim was found
to be in an extreme nose low position…. Had I stopped and
used my checklist I would have taken off normally and not
made a bad situation worse….
No Checklist
Wrong Checklist
and asked me to verify the procedures. I read the QRH and
verified that the procedure required us to shut the engine
down. What I didn’t do is question the title of that
particular checklist. The Captain had handed me an open
QRH and pointed to the “RT ENG OVHT” checklist. I fell
blindly into it. Once we read the checklist...we had tunnel
vision and did not even consider that we might be
proceeding with the wrong checklist…. We ended up
shutting the engine down when it was not necessary…. A
valuable lesson was learned…. Next time…I will look up
my own checklist and back up the Captain with my own
assessment….
It should be noted that training took over and we handled
the checklist with absolute professionalism, except the part
about doing the wrong checklist. It won’t happen again.
Overlooked Checklist Item
■ On takeoff roll, when the airspeed reached 60 knots, I
started to pull the yoke back, but the nose of the aircraft
did not lift. I then pulled back the throttle to abort the
takeoff, applied heavy braking, and ran off the side of the
runway into a swamp. When I examined the plane
afterwards, I found that the control lock had not been
removed from the control yoke. A more thorough preflight
and better use of the checklist would have prevented this
incident.
In a recent report to ASRS, a C172 pilot shared this
valuable lesson: When you’re in a hurry and too rushed to
use a checklist — that’s the time to use a checklist.
■ On our initial descent out of FL330, we observed a RT
ENG BLD OVHT [Right Engine Bleed Overheat] amber
light on my [First Officer’s] panel. I was flying so the
Captain took out his QRH [Quick Reference Handbook]
and started to review the procedures. He read it and
seemed to be in a state of disbelief that the procedures
required us to shut down the engine. He gave me the QRH
By using the appropriate checklist, a crew can diminish or
eliminate the adverse effects of a system malfunction.
But, as this B767 crew learned, the wrong checklist can
lead to inappropriate action.
■ An aircraft swap put us behind schedule, then a
particularly ugly customer service problem…delayed
boarding another 15 minutes.... After pushback and during
the course of doing the after start checklist, the Master
Caution “DOORS” light would not illuminate. [We]
attempted [several procedures] to get the light to illuminate.
　
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