Northwest Airlines Flight 255, an MD-80 crashed shortl

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FROM AIRLINE TO MARITIME
AWO Interregion Safety Committee Spring Meeting
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• ADOPTING AN INDUSTRY BEST PRACTICE

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THE NORMAL CHECKLIST

• Do not trust any altitude
• instrument
• This statement was included on checklists of U.S.
  Air Service airplanes (Air Service, 1920), to an
  era when on-board computers calculate and execute
  precise vertical navigation maneuvers.

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INITIAL RECOMMENDATION

• The NTSB recognized the importance of checklist
  use and its critical role in the safety of flight
  operations in a 1969 recommendation following a
  Pan American World Airways B-707 crash after a
  no-flap takeoff. This recommendation called for

Air carrier cockpit checklists to be reviewed in
an effort to ensure that each list provides a
means of reminding the crew, immediately prior to
takeoff, that all items critical for safe flight
have been accomplished
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TWO MORE ACCIDENTS

• Northwest Airlines Flight 255, an MD-80 crashed
  shortly after takeoff from Detroit Metro Airport
  (Michigan) following a no-flap/no-slat takeoff
  (NTSB, 1988a).
• In the third accident, Delta Air Lines Flight
  1141, a B-727 crashed shortly after lifting off
  from runway 18L at Dallas-Fort Worth
  International Airport (Texas), after a
  no-flap/no-slat takeoff (NTSB, 1989).

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RECOGNIZING THE PROBLEM

• Unfortunately, it took 18 years and a major
  accident before the Safety Board recognized the
  problems with the human factors aspects of
  checklist display and procedures.
• Following the Northwest and commuter accidents,
  the NTSB recommended that the FAA convene a
  human-performance research group to determine
• ...if there is any type or method of presenting
  a checklist which produces better performance on
  part of user personnel

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WHAT IS A CHECKLIST

• The major function of the checklist is to
• Ensure that the crew will properly configure the
  plane for flight
• Maintain this level of quality throughout the
  flight, and in every flight.
• The process of conducting a checklist
• Occurs during all flight segments, and
• In particular, prior to the critical segments of
  takeoff, approach, and landing.
• Note Although these segments comprise only 27
  of average flight duration, they account for
  76.3 of hull-loss accidents (Lautman and
  Gallimore, 1988).

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CHECKLIST OBJECTIVES

• Provide a standard foundation for verifying
  aircraft configuration that will defeat any
  reduction in the flight crews psychological and
  physical condition.
• Allow cross checking among crew members.
• Enhance a team concept for configuring the plane
  by keeping all crew members in the loop.
• Dictate the duties of each crew member in order
  to facilitate optimum crew coordination as well
  as logical distribution of cockpit workload.
• Serve as a quality control tool by flight
  management and government regulators over the
  pilots in the process of configuring the plane
  for flight.

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TYPES OF CHECKLISTS

• Paper
• Scroll
• Mechanical
• Electromechanical
• Vocal
• Display and Pointer
• Computer-Aided (With Feedback Loop)

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PAPER CHECKLIST (NORTHWEST MD-80)
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DISPLAY POINTER CHECKLIST
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CHALLENGE-RESPONSE (METHOD)

• More accurately termed
• challenge verification-response
• Checklist is a backup for the initial
• configuration of the plane
• Here, the pilots use their memory and other
  techniques to configure the plane
• After completing the initial configuration, the
  pilots use the checklist to verify that several
  critical items have been correctly accomplished

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RECOMMENDED PHILOSOPHY

• Checklists should contain, in abbreviated form,
  all the information required by the trained
  flight crew to operate the airplane in most
  situations.
• Normal checklists should be organized by segments
  of flight
• Only procedural steps which, if omitted have
  direct and adverse impact on normal operations,
  should be included

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CHECKLIST STANDARDIZATION

• Standardization of flight-deck procedures between
  different fleets is a factor that is part of the
  operational concept of the airline
• It is obvious that a conscientious flight
  management will set a goal of minimizing the
  differences in operational procedures between
  fleets in order to aid pilots in transitioning
  from one aircraft type to another

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REPUBLIC AIRLINES DC-9
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CHECKLISTDISTRACTIONS INTERPRETATIONS

• Elimination of the vital cross-checking of the
  other crew member
• Disruption of the sequential flow of the
  checklist
• Committing to memory the location of the
  interruption in the checklist sequence

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MENTAL MODELS

• When a certain task is performed repetitively in
  the same manner, operators become experienced
  with the task
• In a sense, they actually create a mental model
  of the task
• With experience, the shape of the model becomes
  more rigid, resulting in
• faster information processing
• Ability to divide attention
• A reduction in workload

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APPROPRIATE FLOW PATTERNS

• Standardization of the checklist flow among
  pilots
• Making the checklist sequence run parallel to the
  initial set up flow-patterns, and thereby
  simplifying the learning process and use of the
  checklist process
• Making the checklist actions logical and
  consistent in the motor movement of the head,
  arms and hands
• Therefore, by using a combination of spatial
  flow-patterns and verbal confirmation, the
  designer can maximize the effectiveness of the
  checklist procedure

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ABNORMAL EMERGENCY CHECKLISTS

• Memory Items
• Expanded Checklists
• Loss of power
• Loss of steering
• Loss of all generators

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COCKPIT / BRIDGERESOURCE MANAGEMENT (CRM)

• Has been a topic of much inquiry in the last
  decade
• With concern being focused on the coordination,
  social processes, and combined performance of a
  multi-pilot flight crew

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CHECKLIST AMBIGUITY

• It is fascinating to note how many ambiguous
  terms can be found in such a verbally restricted
  procedure as the checklist
• The ASRS database has numerous reports where
  checklist responses were improperly called and
  created confusion on part of the other crew
  members
• Many checklists examined by the authors employ
  the ambiguous responses set, check,
  completed, etc. to indicate that an item is
  accomplished

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REPUBLIC AIRLINES DC-9
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MARITIME CHECKLIST APPLICATION

• Watch Change
• Masters
• Engineers
• Deck Crew

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CRITICAL PHASES

• Pre-Locking
• Bridge Transit
• Critical Area Transit Procedures (CATP)

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ABNORMAL PROCEDURES

• Masters
• Engineers
• Deck Crew

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EMERGENCY

• Memory item
• Expanded procedures

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