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Stress, Urgency, Complacency – and Checklists

Human Factors | December 15, 2015

Author: Patrick Mendenhall

“…History doesn’t repeat itself, Gamora, but sometimes it rhymes.”
-Dan Abnett, Guardians of the Galaxy

Atul Gawande, MD, in his 2009 bestselling book, The Checklist Manifesto, takes a historical perspective on the modern aviation checklist.

On October 30, 1935, a demonstration flight of the Boeing 299 – in competition with two other designs for an Army contract – attempted a scheduled demonstration flight. The flight lasted only a few seconds: after take-off, the nose continued to pitch up and after reaching about 300 feet, and the aircraft began a slow roll before crashing back to earth, destroying the aircraft and killing two of the five occupants on board. The cause: failure of the flight crew to remove the gust locks prior to flight.

The Boeing 299 program was nearly cancelled; observers felt that operation of a four-engine aircraft was just too complicated. However, in spite of this loss, the aircraft had previously proven to be vastly superior to its two competitors by several measures. So engineers proposed that if they simply used a written checklist to ensure that certain critical items – such as removal of the gust locks – were completed prior to flight, they could prevent such unnecessary tragedies from happening in the future. According to Gawande, the 299 went on to fly 1.8 million miles without one accident. The program not only survived, but thrived as the US Army Air Corps ended up purchasing over 13,000 of these aircraft, known as the B-17 “Flying Fortress”, a mainstay in World War II.

Nearly eighty years later, a Gulfstream G-IV crashed after it overran the end of the runway during a rejected take-off at Laurence G. Hanscom Field (BED) in Bedford, Massachusetts*. The official NTSB accident report for this crash was recently released and found that, yet again, history nearly repeated itself. In this case, the crew:

  • Failed to disengage the airplane’s gust lock system prior to flight
  • Failed to perform a flight control check
  • Failed to use the FAA-approved checklist in its entirety
  • Failed to note that the gust lock/throttle lever interlock was preventing the engines from reaching the required take-off EPR setting

Each of these, if addressed, could have – likely would have – prevented this accident. The aircraft was completely destroyed and seven passengers and crewmembers were killed.

There were four clear opportunities here to break the “error chain”. As in the case of the B-299, simply following a checklist would have revealed that the gust lock system was still engaged, and this error would have been mitigated before it became an event.

Checklists are designed with great deliberation and purpose. Although every item, situation, or possible condition cannot be addressed, checklists will reveal the most obvious and often the most consequential errors.

The NTSB investigation revealed that failure to consistently use checklists appeared to be a systemic problem within this particular flight department. The discovery that crewmembers sometimes didn’t perform their proper checklists spoke to a greater cultural issue within the organization.

Crew Resource Management (CRM) helps organizations develop and maintain a safety culture. In the example above, a positive and proactive safety culture would have fostered a greater adherence to existing policies and procedures, providing the discipline to use checklists properly and consistently and avoiding this unnecessary and tragic loss.

In this case, history didn’t exactly repeat itself, but it sure rhymed.

*N121JM, registered to SK Travel, LLC, and operated by Arizin Ventures, LLC crashed on May 31, 2014, at about 2140 eastern daylight time.

Patrick Mendenhall is a principle at Crew Resource Management, LLC. He develops and teaches CRM and Human Factors courses and frequently addresses audiences in High Reliability Organizations. He currently works as an A-330 pilot for a major international airline, and is co-author of Beyond the Checklist: What Else Health Care Can Learn from Aviation Teamwork and Safety.

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