As one who has been trying to figure out this concept called flying for longer than I can remember, I’ve always been a little mystified as to why the same accidents seem to keep happening for the same reasons.
Certainly, I’d never be the perpetrator of such dumb behavior…or would I? I rarely fly anything heavier than 11,000 pounds, but that doesn’t excuse me from avoiding checklists.
The very nature of checklists is such that larger, more sophisticated airplanes demand progressively more exotic systems. That, in turn, leads to longer and more complex checklists to manage the airplane.
A recent incident with a corporate Gulfstream GIV jet highlights one of the most common errors pilots make in operating any aircraft, be it a Pitts Special or an exotic twin-turbine business jet.
The pilots failed to follow the checklist.
I know, I know. It’s a mantra preached so often by flight instructors that we pilots sometimes tend to tune it out. The NTSB hasn’t finished its investigation at this writing, but it’s fairly apparent a major contributing factor to the fatal accident listed above was that the flight crew failed to use the pretakeoff checklist and didn’t unlock the elevators. The GIV refused to rotate, ran off the end of the runway, broke up and burned.
That probable cause has occurred over and over again, sadly infinitum. In this case, the crew was very experienced, well rested and not in a particular hurry. The weather was good for the short flight from Boston to Atlantic City, and the rest of the airplane seems to have been in good shape.
This accident came home to me, because I lost a friend several years back for the same reason. He was known as a conscientious pilot who attended Flight Safety once a year to stay current. His airplane was a Cessna 340, and he was departing Santa Monica, Calif. The elevator gust lock was in place, and the pilot failed to remove it during the preflight. Like the GIV above, the airplane ran off the end of the runway into a gully, broke up and burned. The owner/pilot and I were scheduled to leave a few days later on a 5,000-nm trip across the Atlantic to Switzerland.
Pilots sometimes commit another dangerous error of omission on takeoff—failure to properly deploy flaps. Like failing to release control locks, leaving flaps full up on some airplanes can be fatal, especially on many transport category aircraft. Fortunately, most general aviation machines don’t suffer the same consequences if the flaps remain full up for takeoff.
Back in 1988, an MD-82 flying out of Detroit Wayne County Airport crashed immediately after liftoff because the crew had failed to deploy the flaps.
Almost exactly a year later, a Boeing 727 departing DFW also crashed on takeoff. Same problem. The crew failed to follow the takeoff checklist and properly deploy the flaps and slats for takeoff.
Then, there’s me, and I’m not without guilt wen it comes to avoiding checklists. I once departed Long Beach in a new Bellanca Viking 300 with a loose engine oil cap. You’d be amazed how much of a mess one quart of oil makes on a windshield in the time it takes to circle the airport and land.
Another time, I was landing my Mooney at Van Nuys when a jet misunderstood his clearance and pulled out on the runway 1,000 feet down. I went around, of course, and remember thinking, “This will just be a quick orbit, so I’ll leave the gear down.” Right.
Somewhere on the short downwind leg, I noticed the gear was down, so I apparently reacted intuitively… and put it up. About that time, the tower said I was cleared to land, and could I please expedite the approach.
I wrapped the airplane around the base and final turn,s and completely ignored the prelanding checklist (since I had done it a few minutes before). As I was just crossing the threshold, the controller advised, “Mooney 74B, no gear, go around.” I was never advised to call the tower, but I would have deserved it if I had been.
The consequences of not always following the checklist need not always be lethal. Sometimes they’re financial. I was flying a Cessna 421 to the Philippines a few years back and was about two-and-a-half hours out on the first 12-hour, 2,160-nm hop from Santa Barbara to Hawaii when the HF radio went dark. HFs are inordinately subject to power spikes, and a common failure is to simply blow a fuse. ATC takes a dim view of aircraft operating in oceanic airspace without long range radio com, and for that reason, ferry pilots always make it a point to carry extra fuses.
I had skipped right over that item on my ferry flight checklist, thinking, of course, I had several extra fuses for my Kenwood HF. Wrong.
As a result, I was forced to reverse direction and head back to Santa Barbara. I could have bluffed ATC by having the airlines relay my remaining eight position reports, but I would have been faced with questions in Honolulu.
It was an expensive abort, 210 gallons of fuel, plus an additional overnight cost me about $1,200 that came right off the top of my fixed-price contract.
Sometimes, the best intentions only contribute to the problem. Back in the ’60s, Cessna built a light twin with centerline thrust, one engine on the nose and one on the tail. The Cessna Skymaster was planned to be a safer twin, without the curse of asymmetric thrust in the event of an engine failure.
This was far from the first CLT twin, but it was a first for American general aviation. The Germans designed and test flew a push/pull fighter, the Dornier Do-335, during the latter part of WWII. The Skymaster system worked so well that the FAA created a new multi-engine ticket, the centerline thrust rating, confined to pilots in tandem-engine twins.
There were other problems, however. For one, pilots sometimes taxied on the front engine alone to save fuel or unwittingly allowed the rear engine to idle out during taxi without knowing it. (You couldn’t taxi on the rear engine only, as the aft mill would overheat in a few minutes without prop blast from the front engine to keep the rear Continental cool.)
When it came time for takeoff, pilots sometimes forgot that the rear engine wasn’t turning (since it was out of sight) and initiated departure on the front engine alone. It didn’t happen often, but a few times was too many. Needless to say, so we won’t.
Cessna solved the problem by mounting the world’s largest red “alternator out” light to warn that the rear alternator wasn’t on line. Never mind that there were another half-dozen instrument indications a pilot had to ignore to perpetrate this mistake.
The company also revised the pilot manual to suggest that the right (rear engine) throttle go full forward first during takeoff. If there was no response from the airplane, it was a definite hint the rear engine wasn’t running.
Some early general aviation aircraft included a single fuel tank quantity gauge with a selector that could be set on any position, totally independent of the actual tank selector valve. This led pilots to sometimes inadvertently leave the fuel quantity indications on the wrong tank and be totally amazed when the engine quit after draining all fuel from a tank while still indicating adequate fuel. As a result, many manufacturers placed a provision in the checklist that suggested something like, “Selected fuel tank indication should agree with fuel tank actually in use.”
Depending upon the airplane in question, there are probably a thousand other things that a checklist can remind us of, and therein lies the rub. As boring as they may be, we NEED checklists to make certain we don’t forget something important.
At least, I know I do.
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