AN MD82 PIC; PNF; FORGETS TO TURN ON THE INFLT IGNITION WHEN AT THE LOM WHILE ON A VISUAL APCH TO RWY 35L AT OKC; OK.

2000-04 · NASA ASRS report 469160

Date: 2000-04 · Aircraft: MD-82

Anomalies: deviation-discrepancy-procedural-published-material-policy|other-cklist-design

Synopsis

AN MD82 PIC; PNF; FORGETS TO TURN ON THE INFLT IGNITION WHEN AT THE LOM WHILE ON A VISUAL APCH TO RWY 35L AT OKC; OK.

Narrative

PROCEDURAL VIOLATION: LANDED MD80 WITH IGNITION SWITCH OFF IN VIOLATION OF COMPANY CHKLIST AND AFM REQUIREMENTS. SPECIFIC CONDITIONS: THE DSCNT CHKLIST SPECIFIES THAT THE IGNITION WILL BE IN 'A' OR 'B' (ON) 'PRIOR TO LNDG.' AS A TECHNIQUE; I NORMALLY TURN THE IGNITION ON WHEN THE GEAR IS EXTENDED. THUS IT IS CONNECTED WITH SOME SPECIFIC ACTION AND ENSURES THE 10 MIN ON LIMITATION IS NOT EXCEEDED. IN THIS INSTANCE; THE VISUAL APCH WAS COMPLICATED BY STRONG WINDS WHICH REQUIRED A DISCUSSION WITH MY FO ABOUT GENERAL CONFIGN AND WHERE TO BEGIN DSCNT. WE WERE ALSO TIRED AS IT WAS EARLY IN THE MORNING. AS THE PNF; IT WAS MY JOB TO TURN THE IGNITION ON AND RESPOND 'DSCNT CHKLIST COMPLETE.' IN THE RUSH OF THINGS; I FORGOT. I SHOULD ADD THAT THIS OMISSION HAS OCCURRED TO ME NUMEROUS TIMES AND USUALLY INVOLVES ANYTHING SLIGHTLY NONSTANDARD: HIGH APCH; RUSHED FINAL; CONTACTING TWR ABOUT THE TIME THE GEAR IS EXTENDED; HIGH DENSITY ARPT; ETC. CONTRIBUTING FACTORS: 1) NO BACKUP FOR CHKLIST INITIATION. AIRLINE'S POLICY DOES NOT UTILIZE THE 2 MAN CONCEPT WHEN INITIATING CHKLISTS OR IN CONTINUING TO RUN THEM PAST NATURAL BREAKS. THE AOM DOES NOT DESIGNATE WHO WILL INITIATE CHKLISTS. AS A RESULT; THE PNF INITIATES AND COMPLETES MOST CHKLISTS. EXCEPT WHEN USING THE MECHANICAL CHKLIST; ALL CHKLISTS ARE READ SILENTLY. THE PNF IS ONLY REQUIRED TO STATE THAT THE 'DSCNT CHKLIST IS COMPLETE.' THE PF IS OUT OF THE LOOP AS FAR AS INITIATING THE DSCNT CHKLIST OR BEING AWARE OF ITS PROGRESS. BECAUSE THE DSCNT CHKLIST IS READ SILENTLY; UNLESS THE PF DOES HIS OWN SCAN; HE IS NOT EVEN AWARE IF THE OTHER PLT IS ACCOMPLISHING THE CHKLIST PROPERLY. AS A RESULT; IF THE PNF FORGETS AN ITEM; THE PF IS NOT IN THE LOOP TO CORRECT THE OMISSION. THIS IS PARTICULARLY TRUE FOR THE IGNITION AS THE PF IS LOADED DOWN WITH FLYING THE ACFT AND RESPONDING TO THE BEFORE LNDG CHKLIST AND SO IS NOT IN A POS TO MONITOR THE PROGRESS OF THE DSCNT CHKLIST. 2) OVERLAPPING CHKLISTS: THE IGNITION FOR THE FORMER OWNER ACFT IS THE LAST ITEM ON THE DSCNT CHKLIST AND IS THE ONLY ITEM UNDERNEATH THE TITLE 'PRIOR TO LNDG.' IN THE CASE OF THE IGNITION; THIS ITEM IS ACCOMPLISHED WHILE THE BEFORE LNDG CHKLIST IS IN PROGRESS: 2 CHKLISTS ARE IN PROGRESS AT THE SAME TIME! AS STATED ABOVE; THIS OCCURS BECAUSE OF THE TIME LIMIT ON THE IGNITION SYS. TURNING THE IGNITION ON AT 10000 FT; WHICH IS THE PREVIOUS STOP POINT ON THE DSCNT CHKLIST; WOULD ROUTINELY EXCEED THE 10 MIN TIME LIMIT. SO IT MUST BE DONE THIS WAY. RECOMMENDATIONS: 1) CHANGE POLICY AND REQUIRE ALL CHKLISTS (INCLUDING DEFINED BREAKS) TO BE INITIATED BY THE PF; OR CAPT AS REQUIRED. THIS WOULD BRING 2 PLTS INTO THE PROCESS AND INCREASE THE CHANCES OF CHKLIST ACCOMPLISHMENT IN A HIGH CREW WORKLOAD ENVIRONMENT. 2) MAKE CLRLY DEFINED BREAKS IN CHKLISTS AND DEFINE SPECIFIC POINTS (ALTS OR ACTIONS) WHICH WILL TRIGGER THE PF OR CAPT TO CALL FOR CONTINUATION OF THE CHKLIST. THE AFTER TKOF; CLB AND DSCNT CHKLISTS HAVE CLRLY DEFINED BREAKS; BUT THE BEFORE LNDG CHKLIST HAS NONE AND THERE ARE AT LEAST 3 NATURAL BREAKS IN THE FLOW. I KNOW COMPANY FEELS THE MECHANICAL SWITCHES SOLVE THIS PROB; BUT THEY DO NOT SOLVE THE PROB OF HAVING ONE PLT REMIND THE OTHER TO CONTINUE OR COMPLETE THE CHKLIST. 3) REQUIRE ALL CHKLISTS TO BE READ ALOUD SO THAT THE PF STAYS IN THE LOOP. THIS HELPS ENSURE THE ITEMS ARE ACCOMPLISHED; AND ACCOMPLISHED CORRECTLY. 4) REMOVE 'IGNITION' FROM THE DSCNT CHKLIST FOR EX-OWNER ACFT AND PLACE IT IN THE BEFORE LNDG CHKLIST IN THE TIME FRAME WHERE IT BELONGS. CULL OUT DUPLICATION IN THE BEFORE LNDG CHKLIST TO MAKE ROOM FOR 'IGNITION;' TO SAY NOTHING OF DECREASING CREW WORKLOAD IN A HIGH CREW WORKLOAD ENVIRONMENT. (DUPLICATION WOULD NOT BE NECESSARY IF CHKLIST INITIATION PROCS UTILIZED THE 2-MAN CONCEPT.) 5) HAVE THE PF OR CAPT RESPOND ONLY TO CRITICAL ACTION ITEMS ON THE BEFORE TKOF AND BEFORE LNDG CHKLISTS. THIS WILL REDUCE HIS CREW WORKLOAD SO HE CAN TAXI SAFELY OR FLY A BETTER APCH; AS WELL AS MONITOR CHKLIST ACCOMPLISHMENT.

Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.

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