Cautionary Tale - Training and Checklists

[5x5]

I wasn't sure if this fit better in General or the Flight Training forum, but decided this was best as it applies to experienced pilots, not just early on training situations. I found it interesting as I've heard and read any number of comments from some very experienced pilots questioning the usefulness of checklists when you are very familiar with the aircraft you're flying.

Anyway, here it is as food for thought.

IFR Fix: Power, and distraction
December 19, 2014 By Dan Namowitz
It was a short, stressful flight.

Failure of the glass-cockpit avionics occurred during initial climb, pretty much simultaneously with autopilot disconnect. The avionics cooing fan had been flashing a failure alert, but now all displays shut down; no navigation, no communications.

Fortunately, weather was visual. The Beech King Air 200’s pilot navigated back to the airport the old-fashioned way, and used a cell phone to call the FBO to request that they notify the tower.

In the pattern, an attempt to lower the landing gear brought no response, requiring a manual extension. "When (I) used push-to-test gear-down light found lights inoperative and realized had lost all electrical," the pilot explained in the Aviation Safety Reporting System (ACN: 1120983). "Checked generator switches and found I had failed to turn both generators on after ground power start resulting in battery depletion. Reset generators and recovered electrical and nav/coms. Contacted Tower and landed without further incident."

A simple but costly omission. Commenting on likely causes, the pilot cited factors including distraction, a gap in the simulator curriculum, a dead backup battery, and sunglasses.

The embattled King Air pilot attributed the generator-switch omission to distraction while trying to get line personnel to disconnect ground power, not using a checklist "due to long time familiarization with airplane and systems," and a dead backup avionics battery. Sunglasses obscuring annunciator panel displays may have contributed. And the pilot offered an observation revealing a minor but important gap in the proficiency routine: "In recurrent simulator training, always did battery start procedure."

Then, when a real flight diverged from the training scenario, not even the pilot’s "long time familiarization" with the aircraft could stave off a major systems failure.

Dan Namowitz | Aviation Writer
Dan is an aviation writer and flight instructor. He has been a pilot since 1985 and an instructor since 1990.

[Big Pistons Forever]

This is an excellent example of why a robust system of incident and hazard reporting is so important. These are the kinds of practical lessons about the real world Gotcha's that benefit everybody.

It is also has some good Threat and Error Management (TEM) lessons

The Threat , not turning on the generators, was not managed with effective checklist use, leading to the error which resulted in loss of nav displays. From an Operational stand point the Error was well handled in that a good plan was formulated to effect a safe return to the airport but the first opportunity to identify the error at the initial onset of the problem, was missed. The good news was that the problem was identified and the threat successfully Managed.

I want to emphasize that I am not criticizing the pilot. Pretty much everybody, including myself, have made these initially small mistakes only to have them blow up in your face. How you handle them and the lesson you learn are the important take aways.

[GARRETT]

As an IFR school in B.C. says, "Checklists, all they do is work." Anyone can memorize a checklist BUT will you remember it when the s**t hits the fan and you're task saturated or distracted? Your passengers sure hope you do. If any of you plan on flying a 705 category aircraft in the future, do yourselves a favor and start getting into the habit of using checklists religiously.

[Liquid Charlie]

BUT will you remember it when the s**t hits the fan and you're task saturated or distracted?

-- a lot of emergencies have memorized drills that must be completed from memory - these are always followed by a check list which is read -- the point I am making here is that you do need to memorize certain required things and lock them into your muscle memory -- "fly the fuking areoplane" -- is always on the list

[Illya Kuryakin]

As an IFR school in B.C. says, "Checklists, all they do is work." Anyone can memorize a checklist BUT will you remember it when the s**t hits the fan and you're task saturated or distracted? Your passengers sure hope you do. If any of you plan on flying a 705 category aircraft in the future, do yourselves a favor and start getting into the habit of using checklists religiously.

There is no need to memorize entire checklists, other than the few "memory" items on some, thankfully few emergency procedures. Developing a good flow in day to day situations is ( for me, at least) far superior to pulling out a paper checklist, from which you can be distracted, thus missing the entire value of the bloody thing in the first place. Our hero missed both generators. He didn't notice the two lights on his annunciator panel? Are people suggesting that's something he needed to "read"? Learn a flow boy!
Illya

[Big Pistons Forever]

. Our hero missed both generators. He didn't notice the two lights on his annunciator panel? Are people suggesting that's something he needed to "read"? Learn a flow boy!
Illya

So Ilya. It must be nice to be the Skygod that never ever missed a checklist item......

Calling someone a "boy" while stating the obvious "Learn a flow" which since he was trained in the sim he would undoubtedly have been taught ? Really, that is what you see is the lesson to learned in this incident ?

[cgzro]

Just as an aside and not passing judgement because I know how the brain goes to 50% in any unusual circumstance but there are many signs of a non functioning alternator besides inop lamps. You get a wacking big needle displacement on the ammeter and if you have any cigarette lighter powered do-dads they start getting unhappy as the voltage drops. Couple of times when my alternator primary power lug failed the first warning was my ship powered ANR not doing any "NR" but instead going wooka wooka with a flashing low voltage light on the battery case. Pretty hard to miss. I also get a tiny bit of alternator whine on the radio and when that disappears its a dead give away.

Ive not flown much behind glass panel stuff and when I last did it was an Extra 330 with all manner of stuff best ignored during acro with the exception of the teensy weensy oil pressure and temps as microscopic sliders that needed a magnifying glass to read; However dont those things flash low voltage warnings at you? Dont they have built in battery backups that also warn?

[Illya Kuryakin]

. Our hero missed both generators. He didn't notice the two lights on his annunciator panel? Are people suggesting that's something he needed to "read"? Learn a flow boy!
Illya

So Ilya. It must be nice to be the Skygod that never ever missed a checklist item......

Calling someone a "boy" while stating the obvious "Learn a flow" which since he was trained in the sim he would undoubtedly have been taught ? Really, that is what you see is the lesson to learned in this incident ?

Gee BPF, I've read and reread what I posted. Where exactly did I state that I'd never missed a checklist item? Seriously, point it out to me. When something goes south, the checklist is the first thing on my lap. But, I do t need to read "turn generators on", or "put gear down", or, "zip fly" after pissing.
Illya

And "threat and error management". TEM? Seriously? Is that like SYNN? Scratch your nuts now?

[cgzro]

We've all F$$d up a few times, we are just lucky just nobody wrote about it.

[GA MX Trainer Dude]

ACN: 1120983 (1 of 1)

Time / Day

Date : 201309
Local Time Of Day : 0601-1200

Place

Locale Reference.Airport : ZZZ.Airport
State Reference : US
Relative Position.Distance.Nautical Miles : 30
Altitude.MSL.Single Value : 13000

Environment

Flight Conditions : Mixed
Weather Elements / Visibility.Visibility : 10
Light : Daylight
Ceiling.Single Value : 1800

Aircraft

Reference : X
ATC / Advisory.TRACON : ZZZ
Aircraft Operator : Personal
Make Model Name : Super King Air 200
Crew Size.Number Of Crew : 1
Operating Under FAR Part : Part 91
Flight Plan : IFR
Mission : Personal
Flight Phase : Climb
Route In Use.SID : LEJON 2
Airspace.Class E : ZZZ

Component

Aircraft Component : AC Generation
Aircraft Reference : X
Problem : Improperly Operated

Person

Reference : 1
Location Of Person.Aircraft : X
Location In Aircraft : Flight Deck
Reporter Organization : Personal
Function.Flight Crew : Pilot Flying
Function.Flight Crew : Single Pilot
Qualification.Flight Crew : Multiengine
Qualification.Flight Crew : Commercial
Qualification.Flight Crew : Instrument
Experience.Flight Crew.Total : 4300
Experience.Flight Crew.Last 90 Days : 21
Experience.Flight Crew.Type : 2300
ASRS Report Number.Accession Number : 1120983
Human Factors : Other / Unknown
Human Factors : Situational Awareness
Human Factors : Human-Machine Interface

Events

Anomaly.Aircraft Equipment Problem : Critical
Anomaly.Deviation - Procedural : Published Material / Policy
Detector.Person : Flight Crew
When Detected : In-flight
Result.Flight Crew : Became Reoriented
Result.Flight Crew : Landed As Precaution
Result.Flight Crew : Returned To Departure Airport
Result.Flight Crew : Overcame Equipment Problem

Assessments

Contributing Factors / Situations : Human Factors
Primary Problem : Human Factors

Narrative: 1

On climb out experienced loss of both PFD's and MFD on Garmin G-1000 glass panel along with autopilot disconnect. For 2-3 minutes prior had avionics cooling fan failure alert along with 2-3 other avionic component intermittent failure alerts. While assessing alerts all displays shutdown with no NAV/COM. Reverted to back up gages and hand flying. Since it was not IMC elected to return to departure airport using wet compass for navigation. Used cell phone to contact FBO to relay message to Tower of situation and intention to land entering left downwind for active runway. Gear would not lower so began manual extension. When used push to test gear down light found lights inoperative and realized had lost all electrical. Checked generator switches and found I had failed to turn both generators on after ground power start resulting in battery depletion. Reset generators and recovered electrical and NAV/COMs. Contacted Tower and landed without further incident.

Personal assessment of contributing causes: Pilot failed to turn generators on after ground power start and being distracted trying to get attention of line personnel to disconnect ground power. Not adhering to check list due to long time familiarization with airplane and systems. In recurrent simulator training always did battery start procedure. Although pilot was legally current practical competency may not have been at optimum level due to low flight hours in past few weeks. Use of sunglasses in bright light may have dimmed recognition of annunciator panel lights. Avionics standby backup battery did not function although armed. Later tested and found would not hold charge, reason under evaluation.

Synopsis

BE20 pilot reports electrical failure shortly after takeoff with loss of G1000 and communications. The electrical failure is not initially detected but when discovered it is determined that the generators were never turned on after engine starting with a ground power cart.

[GA MX Trainer Dude]

Criminal Negligence

The failure to use reasonable care to avoid consequences that threaten or harm the safety of the public and that are the foreseeable outcome of acting in a particular manner.



It is what it is!!

Mx

[Diadem]

Illya, the pilot admitted that this incident was a result of his failure to follow the checklist, and yet your advice is basically "Learn how not to use the checklist"? The reason we use them is to make sure we've covered everything. Do an after-start flow, sure, but then run through the checklist to make sure you've done everything. What could that hurt, besides perhaps your pride?

[the goal is soul]

5x5: Great source material for a post!

Big Pistons Forever: I agree with your line of thinking, but I'll toss out another take on the TEM perspective.

We only have the context that the reporter offers, but I would consider distraction as the threat; he was using a non-standard start procedure (for him) that perhaps broke his normal after-start habit patters that usually keep him out of trouble. The error could be considered that the checklist wasn't used/completed by memory/not run to completion, though he trapped his error while troubleshooting the problem.

The training curriculum is a good example of a latent threat...a seemingly innocuous condition that is just lying there in wait for the right circumstance to present itself to bite you in the ass.

I also agree with you on the value of self-reporting like this. Shows a fair amount of maturity to voluntarily share his mistakes...that, or there were enough witnesses that he couldn't hide it even if he wanted to. ASRS in the US protects everyone who submits though...not just crews of SMS operators like in Canada.

"Checklists, all they do is work."

I like that. I would suspect that checklist culture/compliance varies considerable through different types of operations in this country. I also think that the way you used a checklist in your commercial/MIFR training wouldn't necessarily reflect how you would use one in your operational environment. I see where Illya is coming from ("how hard is it???"), but at the same time, I wonder how clearly the checklist policies are laid out in the SOPs, how much training was given to something seemingly obvious and yet so important, and most relevant in my opinion, do senior pilots with the most influence use checklists by the book, or do they do it "their way"?

So here's my question to the thread: (1) Who best taught you how to use a checklist in the cockpit; and (2) is that training stronger than the checklist culture on the line in your operation?

[GyvAir]

I suspect there is a bit more to this story than opting not to use the checklists during start or before takeoff and having it come back to bite the pilot.

In my experience, it’s not the norm with a KA200 to request an external power start. Nor, as suggested by the report narrative was it the norm for this pilot to be doing an external power start, which leads me to believe/speculate that the main aircraft battery was found to be depleted prior to starting the engines and possibly even depleted more with an attempted engine start prior to calling for a start cart. Also, the fact that they lost all power very early in the flight would indicate that there was very little reserve left in the main batter prior to the external power start and/or takeoff. I’m assuming that there was very little hold time between engine start and takeoff. I would like to think that if one was holding for 5, 10, 20 minutes that they might do an extra scan or two around the cockpit to make sure things are normal. Reach over and press the annunciator test, or flip it between bright and dim. Maybe look up at the ammeter, and turn the little knob, just for fun, etc.

Anyways, to get to where I’m going on this, it sounds to me as though it’s quite possible the pilot made a conscious decision to take off with a depleted main battery. If he had been following procedure, he would have sat with the generators running, monitoring the ammeter until the battery charge rate had fallen below the prescribed level. I believe there is also a battery charge annunciator on the 200 that is supposed to be extinguished prior to takeoff as well, although I’m not sure that would be illuminated if both generators offline anyway.

The dead and unwilling to take a charge avionics battery leads me to wonder if it could have been a scenario where prior to the cart start, the aircraft had been accidentally left sitting with the battery and avionics master on, draining the main battery until the relay unlatched and then draining the backup battery to nothing. The annoying and distracting delay in getting the ground power cart disconnected would have given a the main battery a quick partial charge.. just enough to get them in the air. Pure speculation, of course.

[PilotDAR]

Not criticizing the pilot, or delving too far into the "use of checklist" subject, I do see an aspect of "being in the groove", which is not always a good thing. If you do the same thing with the same machine time after time, the "different thing one day" can be the threat to safety. Need it be? A GPU start is hardly an abnormal circumstance, but the fact that is was distracting means to me that the pilot was too far in the groove. Once bumped out of the groove, things went more bad that acceptable. It sounds as though some elements of this event were a rather blatant training failure. This pilot was trained to be in the groove. If the pilot's muscle memory excluded a GPU start procedure, because it had never been sim trained, that's a problem. That should be a red flag for the pilot, something's different, revert to the checklist.

I fly my 150 like I drive my car, and most of the year, about as frequently. After 28 years, flying that plane just flows from me. But there are days when I'll fly two or three very different planes (my diversity record was Lake Amphibian, Tiger Moth and Caravan in a day). I find that flying the other planes gets me out of the groove very quickly. The cockpit is not "normal", so I'm taking my time to assure configuration (and yes, use the checklist in the Caravan).

The threat is complacency - being too far in the groove. It's okay to be in the groove with a plane you fly regularly, as long as you are also being agile of mind to manage non standard to abnormal events. Or recognize that an aid would be useful, and use the checklist properly (which means that if you are interrupted, you start again from the beginning).

[Liquid Charlie]

In the example used -- I gather it was single pilot and I'm sure that most who fly single pilot on the commercial side do not physically read a check list -- but rather use a flow check -- which is also alive and well in transport category aircraft as well as any time you have a "do and read" which follows up your flow with a read check list in a multi crew environment but single pilot as in this case where he is hand flying he caught the problem likely by a flow check and not a check list on his lap - I for one see nothing wrong with flow checks - the killer is distraction or being in a hurry - look back on your own fuk ups - don't worry -- no one has to tell and I'll bet being in a hurry is the #1 culprit and second likely is fatigue - now little things like divorce or anything where you might have you head up your ass -- commonly referred to these days "human factors" dump us in the shit every time -- trick is to recognize this and be methodical and careful -- check lists are a aid because there is no way we can remember all the steps required when securing or trouble shooting but the fact remains that to get to the emergency check list stage you need to do the memory items first and keep the greasy side down -- items where there are no drill items are not going to immediately swat you out of the sky but the biggest errors I have seen in training are a flurry of hands and feet at hyper speed before things have had a chance to be properly dealt with -- or the other extreme where the candidate just sits there with a complete brain fart -- methodical and deliberate action is where it should be and always remembering to fly the aeroplane - surprising how often this is forgotten - classic in the Florida swamp

To sum the ramblings up -- check list as SOP's are tools and should be used -- but again they are guidelines and do not cover all situations so we should not toenail ourselves into blindly following them if it affects safety -- for single pilot flow checks makes much more sense (not of recreational occasional renters but for commercial drivers) -- it's up to the individual if they feel they need to follow up a flow check with a written check list but remember this - it removes you from your first job -- flying the aeroplane as for me I never did but then again we didn't use written check lists when I learned to fly

[Jungle Jim]

I watched a beautiful Navion land gear up this summer at Hanover. His first flight of the year and no check list to be seen in the cabin.

Jim

[Illya Kuryakin]

I watched a beautiful Navion land gear up this summer at Hanover. His first flight of the year and no check list to be seen in the cabin.

Jim

He was probably running a paper checklist to keep folks like BPF happy, and his cell phone went off just before the "put gear down" part of his "crutch" and he missed it. Too bad though, Navions are really cool old airplanes.
What's wrong with....."got the flaps, got the gear, runway's clear, time for beer" as an over the fence mantra? It's what I use.
Illya

[Cat Driver]

I watched a beautiful Navion land gear up this summer at Hanover. His first flight of the year and no check list to be seen in the cabin.

There is more than not having a written check list in the cabin missing when this happens.

[Big Pistons Forever]

This has turned into an interesting discussion. One point not mentioned was the somewhat critic comment about sunglasses. This is actually a non trivial point because the generator warning lights in the King Air are yellow. Certain sunglass tints make yellow lights harder to see especially if there is s bit of confirmation bias going on.

The comment about the state of the battery is also a good observation. I have twice shot IFR approaches in IMC with only the battery providing power after a total generating system failure. This has caused me to pay attention to the state of the battery not take off if I was not confident the battery was well charged.

TEM is not some magic potion it is simply a way to describe what experienced good pilots have always done. Personally I find it a very useful training tool as it forces the "What happened" discussion to be a lot deeper than telling the "boy" to "do a flow".

Safety in aviation is moving from the traditional "Find out who screwed up and then fire their ass" to "Let's look at what went wrong and ask ourself why that happened". This approach can often identify traps or Gotcha's that mean the incident accident is likely to happen again. It doesn't excuse willful actions or neglect or personal incompetence, instead it recognizes the reality that humans make mistakes. Often simple procedural changes can greatly reduce the chance a mistake can be made.

I have been flying for 38 years and I have yet to make a perfect flight , so personally I find good value in reading these kind of reports and asking myself if I could fall into the same traps that befell the reporter