Number 292
January 2004
A Monthly Safety Bulletin from The Office of the NASA Aviation Safety Reporting System
P.O. Box 189, Moffett Field, CA 94035-0189

Checklist Checkup

Doctor reading a chartAn 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:

1. Failure to use a checklist.

2. Use of the wrong checklist.

3. Checklist flow interrupted.

4. Checklist item(s) overlooked.

Recent examples of these errors are detailed in the following ASRS reports:

No Checklist

In 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.

Wrong Checklist

By 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.

Interupted Checklist

Use 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.

Overlooked Checklist Item

Completing every item on the checklist is the key to "unlocking" the secret of flight.

Gear Up Checkup

Landing Gear LeverA 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.

Two 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.

The 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.

An Extension Course in Six Lessons

1. Traffic is often cited as a distraction in gear up landings.

2. Distractions can also be self-induced.

3. A thorough passenger briefing might have prevented this distracting situation.

Aircraft making an accuracy landing on a runway4. Although an "accuracy" landing does entail hitting a specific point on the runway, taxiing beyond that point is easier when the gear are extended.

5. 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.

6. Raising the landing gear "temporarily" also raises the odds of a gear up landing.


ASRS Recently Issued Alerts On...
MD80 galley fire incident
Western U.S. airport SID chart confusion
Western U.S. airport baggage loading procedure
B737-200 loss of primary altimeter & airspeed indicators
Southern U.S. airport hold short line marking
December 2003 Report Intake
 Air Carrier/Air Taxi Pilots
 General Aviation Pilots