Callback and reprinted with permission from FAA Aviation News
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 Aviation Safety Reporting System (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
3. Checklist flow
of these errors are detailed in the following ASRS reports:
In a recent report to ASRS, a Cessna 172 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.
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
By using the appropriate checklist, a crew can diminish or eliminate
the adverse effects of a system malfunction. But, as this Boeing 767
crew learned, the wrong checklist can lead to inappropriate action.
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 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.
Use of a checklist insures that standard procedures are followed and
all systems are properly set even when distractions interrupt the
normal sequence of events. This Boeing 737 crew thought they were all
set for takeoff until the 'unfinished checklist' warning horn sounded.
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. Now we've gone from mildly
irritated to irritated. We then consulted the MEL [Minimum Equipment
List] for possible dispatch issues. About this time, the problem
decided to cure itself. After being off on the Master Caution tangent
for several minutes, the fact that we were not finished with the
pre-takeoff checklist did not register. I called for taxi, and
everything in our world seemed okay until the takeoff configuration
horn sounded as I advanced the thrust levers for takeoff.... I
returned the thrust levers to idle and the Captain called for taxi off
the runway. We realized that we had allowed the distraction after
pushback to cause us to miss the completion of the pre-takeoff
checklist and the flaps were not extended.... Now I am going to clip
the checklist to the yoke until the pre-takeoff checklist is complete.
If the checklist is still out of its holder during taxi, I should be
asking myself why....
Completing every item on the checklist is the key to 'unlocking' the
secret of flight.
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.
A review of the ASRS database indicates that approximately 100 gear up
landing incidents have been reported each year for the past five
years. Ninety-six unintentional gear up landings were reported in
distraction and preoccupation, are common to most of the gear up
incidents reported to ASRS. In the usual scenario, a distraction
occurs at the time when the gear would normally be lowered and the
pilot then becomes preoccupied with the approach and landing.
The last six
unintentional gear up landing reports from 2003 confirm the need to
overcome distractions and preoccupation during the landing phase.
These incidents (all remarkably similar to the 90 reports that
preceded them) involve light aircraft. The lessons, however, are valid
for any aircraft with retractable gear.
Course In Six Lessons
1. Traffic is often cited as a distraction in gear up landings.
...Turning short final I was doing my final checks....'Gear down'
would have been at this point, but the controller said, 'Prepare to go
around. Number one aircraft is not off the runway yet.' I could see
that the aircraft was about to clear at the far end of the runway and
said, 'I think he will be clear' and that seemed to satisfy the Tower.
By this time I had crossed the fence and Tower cleared me to land.
Shortly thereafter the controller called out, 'Go around. Gear up.'
Five feet off the runway was not enough time to arrest the descent.
can also be self-induced.
...I had to make
an extended downwind for two incoming planes on final. After turning
behind the last plane and becoming established on final approach, I
began following the glide slope for practice. My concentration on
sticking to the glide slope...distracted me from doing a proper
landing checklist which included putting the gear down. Perhaps a foot
off the runway, I realized that the gear was still up, but it was too
late even though I applied go around power...
3. A thorough
passenger briefing might have prevented this distracting situation.
accidentally pulled the emergency release handle ejecting the escape
window.... I could not hear [the Tower] very well due to the air
entering the open window.... I was able to understand that I was
cleared to land. I did not lower the gear as I would normally on the
downwind leg and with the confusion of trying to watch out for [my
passenger] and fly the plane under these adverse conditions, I forgot
to lower the landing gear as planned on final.... A luggage pod
absorbed all of the stress with minor scraping of the bottom of the
4. Although an
'accuracy' landing does entail hitting a specific point on the runway,
taxiing beyond that point is easier when the gear are extended.
The landing was
intended to be a short approach, power off, accuracy landing.... As we
went from number three to 'Cleared to land number one' on short
approach, I...now concentrated on an aiming point to make an accurate
landing, using flaps as necessary, and flying the airplane.... I did
not hear, or it did not register with me, that the gear warning horn
was sounding. I did hear it after the gear up landing....
5. Lowering the
landing gear should always be considered a two-part process. In this
incident the pilot accomplished the first step - putting the gear
handle down, but failed to perform the second step - confirming a down
and locked indication.
...This was [my]
first night landing in a small aircraft at an uncontrolled field
without ILS guidance. I am accustomed to landing on Category II and
III ILS runways at major airports. [I] was fully occupied with flying
a stabilized approach with only VASI guidance and failed to notice
that the 'three green' indication was missing. [I] did an admirable
job maintaining a stabilized approach and touched down on the runway
centerline in the touchdown zone. If only the landing gear had been
extended it would have been a really nice landing...
6. Raising the
landing gear 'temporarily' also raises the odds of a gear up landing.
On a visual
approach I put the gear down, but as I was flying over the city
buildings, I lost some altitude. I retracted the gear because I
thought that in the event of an engine failure I would not reach the
runway. As I circled to land, I focused on the landing and forgot to
put the gear down.
originally appeared in the January 2004 issue of Callback, a monthly
safety bulletin from NASA's Aviation Safety Reporting System.