FAA review of National Transportation Safety Board (NTSB) accident data
revealed that during the period 1983 to 1993, approximately 279 aircraft
accidents occurred in which a checklist was improperly used or not used.
A review of ASRS "checklist" related reports for 2003 suggests
that many of the same errors identified by the FAA and NTSB continue
to be reported. The most common checklist errors include the following:
Failure to use a checklist.
Use of the wrong checklist.
Checklist flow interrupted.
Checklist item(s) overlooked.
examples of these errors are detailed in
the following ASRS reports:
a recent report to ASRS, a C172 pilot shared this valuable lesson: When
you're in a hurry and too rushed to use a checklist that's the
time to use a checklist.
felt okay until just after touchdown. I veered to the right...and
I was unable to correct. I continued off the runway, and skidded
into the dirt.... After coming to a stop, I brought the plane back
onto the runway. I decidedjust to takeoff and get out of there as
quickly as possible.... I did not look at my checklist as I always
do. At takeoff speed I began to rotate but the plane did not seem
to respond. My attention diverted and I again drifted to the right.
Nearing the end of the runway, I hit the brakes hard and skidded
to the left off the runway and down an embankment...
of taking a breath and following normal procedure after the near
crash landing, I was worried what others would think and I tried
to depart the area as quickly as possible. Upon inspection of the
plane the trim was found to be in an extreme nose low position....
Had I stopped and used my checklist I would have taken off normally
and not made a bad situation worse....
using the appropriate checklist, a crew can diminish or eliminate the
adverse effects of a system malfunction. But, as this B767 crew learned,
the wrong checklist can lead to inappropriate action.
of a checklist insures that standard procedures are followed and all
systems are properly set even when distractions interrupt the normal
sequence of events, This B737 crew thought they were all set for takeoff
until the "unfinished checklist" warning horn sounded.
aircraft swap put us behind schedule, then a particularly ugly customer
service problem...delayed boarding another 15 minutes.... After
pushback and during the course of doing the after start checklist,
the Master Caution "DOORS" light would not illuminate.
[We] attempted [several procedures] to get the light to illuminate.
Now we've gone from mildly irritated to irritated. We then consulted
the MEL [Minimum Equipment List] for possible dispatch issues. About
this time, the problem decided to cure itself. After being off on
the Master Caution tangent for several minutes, the fact that we
were not finished with the pre-takeoff checklist did not register.
I called for taxi, and everything in our world seemed okay until
the takeoff configuration horn sounded as I advanced the thrust
levers for takeoff.... I returned the thrust levers to idle and
the Captain called for taxi off of the runway. We realized that
we had allowed the distraction after pushback to cause us to miss
the completion of the pre-takeoff checklist and the flaps were not
extended.... Now I am going to clip the checklist to the yoke until
the pre-takeoff checklist is complete. If the checklist is still
out of its holder during taxi, I should be asking myself why....
every item on the checklist is the key to "unlocking" the
secret of flight.
takeoff roll, when the airspeed reached 60 knots, I started to pull
the yoke back, but the nose of the aircraft did not lift. I then pulled
back the throttle to abort the takeoff, applied heavy braking, and
ran off the side of the runway into a swamp. When I examined the plane
afterwards, I found that the control lock had not been removed from
the control yoke. A more thorough preflight and better use of the
checklist would have prevented this incident.
review of the ASRS database indicates that approximately 100 gear up
landing incidents have been reported each year for the past five years.
Ninety-six unintentional gear up landings were reported in 2003.
factors, distraction and preoccupation, are common to most of the gear
up incidents reported to ASRS. In the usual scenario, a distraction
occurs at the time when the gear would normally be lowered and the pilot
then becomes preoccupied with the approach and landing.
last six unintentional gear up landing reports from 2003 confirm the
need to overcome distractions and preoccupation during the landing phase.
These incidents (all remarkably similar to the 90 reports that preceded
them) involve light aircraft. The lessons, however, are valid for any
aircraft with retractable gear.
Extension Course in Six Lessons
Traffic is often cited as a distraction in gear up landings.
short final I was doing my final checks.... "Gear down"
would have been at this point, but the controller said, "Prepare
to go around. Number one aircraft is not off the runway yet."
I could see that the aircraft was about to clear at the far end of
the runway and said, "I think he will be clear" and that
seemed to satisfy the Tower. By this time I had crossed the fence
and Tower cleared me to land. Shortly thereafter the controller called
out, "Go around. Gear up." Five feet off the runway was
not enough time to arrest the descent.
Distractions can also be self-induced.
had to make an extended downwind for two incoming planes on final.
After turning behind the last plane and becoming established on final
approach, I began following the glideslope for practice. My concentration
on sticking to the glideslope...distracted me from doing a proper
landing checklist which included putting the gear down. Perhaps a
foot off the runway, I realized that the gear was still up, but it
was too late even though I applied go around power....
A thorough passenger briefing might have prevented this distracting
[passenger] accidentally pulled the emergency release handle ejecting
the escape window.... I could not hear [the Tower] very well due to
the air entering the open window.... I was able to understand that
I was cleared to land. I did not lower the gear as I would normally
on the downwind leg and with the confusion of trying to watch out
for [my passenger] and fly the plane under these adverse conditions,
I forgot to lower the landing gear as planned on final.... A luggage
pod absorbed all of the stress with minor scraping of the bottom of
Although an "accuracy" landing does entail hitting a specific
point on the runway, taxiing beyond that point is easier when the gear
landing was intended to be a short approach, power off, accuracy
landing.... As we went from number three to "Cleared to land
number one" on short approach, I...now concentrated on an aiming
point to make an accurate landing, using flaps as necessary, and
flying the airplane.... I did not hear, or it did not register with
me, that the gear warning horn was sounding. I did hear it after
the gear up landing....
Lowering the landing gear should always be considered a two-part process.
In this incident the pilot accomplished the first step putting
the gear handle down, but failed to perform the second step confirming
a down and locked indication.
Raising the landing gear "temporarily" also raises the odds
of a gear up landing.
a visual approach I put the gear down, but as I was flying over the
city buildings, I lost some altitude. I retracted the gear because
I thought that in the event of an engine failure I would not reach
the runway. As I circled to land, I focused on the landing and forgot
to put the gear down.