MD-11; MD-10 CAPT RPTS NEWLY ISSUED EMER CHKLISTS AND QRH ARE CONFUSING; POORLY ORGANIZED; AND ARE HARD TO USE.
Synopsis
MD-11; MD-10 CAPT RPTS NEWLY ISSUED EMER CHKLISTS AND QRH ARE CONFUSING; POORLY ORGANIZED; AND ARE HARD TO USE.
Narrative
MD11 EMER CHKLIST. OVER A YR AGO; A NEW FORMAT FOR THE MD-11 EMER/ABNORMAL CHKLIST WAS ENACTED. THE COMPANY REALIZED THAT THE OLD FORMAT WAS TOO CUMBERSOME FOR A TWO-MAN CREW. MAJOR CHANGES IN THE FORMAT OF THE CHKLIST WERE MADE AND THE QRH WAS CREATED. IT WAS HOPED THAT THE NEW FORMAT WOULD MAKE OPS MORE EFFICIENT AND SAFER FOR TWO MAN CREW OPS. UNFORTUNATELY; THE OPPOSITE HAS OCCURRED. IN TRAINING; INSTRUCTORS HAVE HAD TO POINT OUT THAT THE NEW QRH CHKLIST HAS NUMEROUS FLAWS AND A CONFUSING FORMAT. THE REASON FOR THE FLAWS AND CONFUSING FORMAT IS APPARENTLY INTERFERENCE BY COMPANY LAWYERS AND THE FAA. THE FINAL CHKLIST WAS NOT A PRODUCT OF FLT TRAINING EXPERTS OR PLTS; BUT A PRODUCT OF BUREAUCRATS. THE COMPANY HAS DISPLAYED NO DESIRE TO CHANGE OR IMPROVE THIS SERIOUSLY FLAWED QRH DUE TO LEGALITIES. THESE ARE EXAMPLES OF JUST A FEW OF THE PROBS WITH THIS EMER CHKLIST: PROCEDURES ARE BASED ON YES/NO DECISION STATEMENTS THAT ARE NOT PHRASED AS QUESTIONS. THESE AMBIGUOUS DECISION STATEMENTS CAN LEAD TO CONFUSION AS TO WHERE TO GO FOR THE NEXT STEP. PAGE NUMBERING IS CONFUSING AND COMPLEX. FOR EXAMPLE THE ENG FIRE SEVERE DAMAGE PROC IS ON PAGE B-A1-A-A. THE CHKLIST FREQUENTLY HAS YOU REFER TO OTHER CHKLIST WITHIN THE QRH WITH NO REFERENCE TO SECTION OR PAGE NUMBER. THE ENG FIRE SEVERE DAMAGE CHKLIST TELLS THE CREW TO REVIEW THE SECOND ENG FAILS ON FINAL APCH CHKLIST. NO PAGE REFERENCE NUMBER IS GIVEN FOR THIS REVIEW. INSTEAD; THE CREWMEMBER HAS TO WASTE TIME SEARCHING THROUGH A CONFUSING AND COMPLEX PAGE NUMBERING SYS. THIS IS TYPICAL OF THE CHKLIST AS A WHOLE. THE END RESULT IS THAT IT IS VERY DIFFICULT FOR A CREWMEMBER TO FIND AND EXECUTE THE PROPER CHKLIST IN A TIMELY MANNER IN AN EMER ENVIRONMENT. EMER AND ABNORMAL PROCEDURAL STEPS AND NOTES ARE ALL PRINTED IN THE SAME FONT. IT IS EASY TO SKIP A VITAL PROC. THE TWO ENG INOP CHKLIST IS LOADED WITH NUMEROUS NON-CRITICAL NOTES AND TABLES THAT SHOULD BE PLACED AT THE END OF THE CHKLIST. THIS MISPLACED INFO DESTROYS THE CONTINUITY OF THE CHKLIST. AS A RESULT CREWMEMBERS EASILY GET LOST IN THE MIDDLE OF THE CHKLIST AND MISS VITAL STEPS. NORMAL CHKLIST ARE NOT INCLUDED IN THE ENG OUT EMER PROCS. ONCE AGAIN; THIS RESULTS IN MORE CONFUSION AND CHANCE OF THE CREW MISSING A VITAL STEP. MD-11S HAVE TWO TYPES OF ENGS; GENERAL ELECTRIC AND PRATT AND WHITNEY. GE AND PW CHKLIST ARE COMBINED LEADING TO ADDED CONFUSION. A CONFUSING SYS OF 'GE OR PW START'- 'GE OR PW END'- 'GE OR PW START'- AND EVENTUALLY 'END OF PROC' LEADS TO CONFUSION AND INCREASES THE CHANCE OF CREW ERROR OR MISUNDERSTANDING. GE/PW CHKLIST SHOULD BE SEPARATE INDIVIDUAL CHKLIST. GE HIGH EGT PROC DOES NOT AGREE WITH THE LIMITATION SECTION OF THE AIRPLANE FLT MANUAL. ADDED CONFUSION RESULTS DUE TO MD-11 AND MD-10 ENG; LIMITATION; AND SYS DIFFERENCES. THESE ARE ONLY A FEW OF THE FLAWS WITH QRH CHKLIST. IT WAS MY HOPE THAT MGMNT WOULD HAVE FIXED THIS CHKLIST LONG AGO. IT IS NOW APPARENT THAT THEY ARE CONTENT WITH THE STATUS QUO. LAWYERS AND BUREAUCRATS SHOULD NOT WRITE A FLT OPS CHKLIST.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.