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SAFETY ALERT: WHERE DID OUR MNEMONICS GO!?

NICHOLAS CHRISTIE provides his opinion on the risks of always relying on written checklists. (Article originally published at www.aopa.com.au)

When I started flying, my instructor handed me a green covered, floppy-bound handbook with a photocopied list of aircraft speeds, a map of the airport, the phonetic alphabet – and a list of ‘checklists’ to learn. I took the book home and – as any enthusiastic teenage flying student would do – kept the book beside my bed, committing all the information to memory. I would practice my radio calls and checklists while watching TV and even when I was (supposed to be) doing my homework. Of course, most of the information didn’t mean much to me at the time because I hadn’t yet learned about the full contextual landscape upon which it was based. But I learned it nonetheless. And I’m glad – twenty-nine years later – that I did.

We all know that in many complex operating environments, such as when flying an aircraft, checklists have proven themselves to be vital for safety. They aid the pilot(s) in the proper configuration of the aircraft, irrespective of any reduction in the flight crew’s psychological and physical condition or other distractions or factors.

In a multi-crew environment, they allow mutual supervision (cross checking) among crew members and they keep every member of the crew aware of the aircraft’s status and readiness. In this environment, they also split the crew workload – and clearly define the duties of the crew. As long as they are well-written (‘clustering’ into logical groups is one of the keys here) and properly executed, they improve efficiency and workflow of the crew and potentially improve the quality and amount of time dedicated to the duties of flying the aircraft.

But, improper use (or non-use) of checklists have also been cited as either a contributing factor, or the likely cause of accidents. And, we know that when checklists fail, it’s usually a human issue.

In a NASA report entitled ‘Human Factors of Flight-Deck Checklists: The Normal Checklist’ (1990), the authors summarise that:

“Checklist performance is affected by the way individuals perform as a crew. Poor crew coordination and diminished role structures can lead to omissions and mistakes. And when these omissions interact with component failure, the result may be an incident or an accident… The unique interaction between checklists, humans, machines, and the operational environment, makes the checklist problem a true human factors issue.”

In a multi-crew environment, the use of properly designed checklists, correctly executed, reduces the possibility of failure, with airlines and manufacturers around the world insisting that they are almost always ‘read’ out loud by one crew member and executed / crosschecked by the other. This strict approach is universally regarded as the safest, and most efficient in working together to prevent avoidable accidents and ensure smooth crew performance.

And, in a single pilot operation, checklists are very important, too. Depending on the operator’s requirements and the aircraft manufacturer’s recommendations, written checklists are often used, particularly when the pilot is operating a more complex type, or in operations that deem the written checklist more safe than anything alternative.

In this case, the single pilot will be required to refer to, then recite (often read out) the checklist item, and finally, to execute the checklist item themselves. This can add significant workload and pressure compared to the multi-crew environment, with the risk of human ‘failure’ more significant both in the checklist activity itself and the inability to cross-check, as would be the case in a multi-crew scenario. This has sadly led to a number of accidents over the years.

The major problems in a single pilot scenario an include distractions during the checklist execution impeding the check item (eg. due to unexpected radio calls, traffic or a suddenly high workload), incorrect or inadequate performance of the checklist item(s), or entirely missing the checklist itself. These scenarios can significantly hinder the effectiveness of the checklist itself and lead to human failures that can cause accidents, or combine with other factors to have the same result. And they can occur whether the single pilot has a written or memorised checklist. To err, sadly, is human.

But it is in single pilot recreational flying, particularly when flying less complex types, that many instructors and other commercial pilots believe that the most consistently effective (and safe) checklist comes in a series of learned ‘mnemonics’ that can be applied to practically every aircraft that the pilot flies, or adapted to suit other types, rather than in written checks that are read, recited and performed.

I include myself in this group.

A ‘Mnemonic’, as most of us know, is a system (commonly letters) which assists us in remembering something. And when committed to memory, can be recalled by the pilot of a light recreational type at a given point during a flight to execute the relevant checklist – quickly, effectively and easily. And without having to find the checklist, read from it, execute the item and return to the list.

The first reason that this group of pilots agrees with such an approach is that the pilot in command of a light aircraft has a lot to already think about, do and say – and the act of referring to – and then reading from – a list can act as a source of distraction from the main goal of actually flying the aircraft. If the checklist is committed to memory and broken down into relevant ‘clusters’ (such as a letter of the alphabet), within a larger group (the ‘mnemonic’), it can be easily recalled then executed quickly, allowing for the pilot to continue conducting the other tasks required of them.

The physiology is clear. The process of finding, recalling and reading requires significantly more effort (and time) than the option of recalling and doing what is required. The act of holding a checklist while flying is one example. And even if one was to have, say, a digital screen to check items off, the act of scrolling to recall the correct checklist, fixate the eyes on the checklist item and carry it out is more taxing than the alternative. Certainly for most pilots.

As a GA flight instructor, I have seen a few students try – and fail – to read checklist items in a cockpit. In one case, a student insisted on reading a published ‘after start’ checklist, and the aircraft (a Cessna 172) started to roll forward. If I wasn’t there, he would have certainly contacted the aircraft parked opposite and damaged both Cessnas, possibly injured himself (or someone else) and at very least, dinted his pride. If he had practiced the alternative approach (that I had always suggested) his eyes would have been on the dash, and his peripheral vision would have draw his attention to our slow speed across the ground.

Let’s take another example, this time focused on the classic danger of a fast, retractable undercarriage Bonanza A36 during approach to land at a busy field. With four other aircraft in the circuit pattern, three ahead, our Beechcraft has an airspeed of 130kts (just having turned downwind) and has a Cessna 150 ahead on mid-downwind and a closing speed of 40kts. Even with a wide circuit, the pilot of the Beechcraft MUST watch the Cessna to ensure safe separation. This can be achieved while conducting a memorised mnemonic checklist. But it could never be the case while reaching for, reading off and executing a written list.

Secondly, even if the gear is forgotten on downwind (for whatever reason), the mnemonic that my instructors taught me (and many others practice as well) would always be executed on final – to catch the error. Besides, taking out a checklist to read it on final is downright difficult (and dangerous) and I encourage anyone who disagrees to simply try it, however experienced.

OPINION: “There are always examples where referring to the flight manual, or a series of checklists is always safest”.

There’s another problem here. What if the computer fails (if there is a digital list) or the pages in the checklist book are missing or unreadable? The pilot that knows nothing else other than to rely on a written list, is less effective without it. Perhaps even relying simply on instinct alone to make sure the aircraft is properly setup for that phase of flight.

In the military, checks in faster types are learned, by ‘heart’. God help the pilot that pulls out a checklist while conducting a formation flight, or low level aerobatic sortie, or precision manoeuvre involving troops, time constraints or enemy fire – or all three. You get my point. It just doesn’t happen.

Of course, there are special types like some old warbirds and other aircraft types where the generic mnemonic doesn’t fit, and written lists prove safer – on balance. And that’s ok. There are always examples where referring to the flight manual, or a series of checklists is always safest. Emergencies spring to mind – although most in a light aircraft either have a mnemonic associated with it, because there’s usually not much time to refer to the book. Your instructor will always assist you to find the best approach.

With more students now enrolling in ‘150 hour’ Diploma of Aviation type courses, and the world’s airlines keen to teach the ways of the multi-crew environment from early on, I see an argument for introducing the concept of checklists in a multi-crew or dual instructional ‘role-play’ in the cockpit. Sure. That makes sense.

But, for the rest of us – who will never be part of a multi-crew operation – life in the cockpit of a small recreational craft can be very different. While we should always be aware of the need to always follow the manufacturer’s requirements for each aircraft type, for most light aircraft our memorised mnemonics can take the pilot through all the required items, in similar or identical ‘clusters’, for the required phases of flight.

To my mind, there is an anecdotal trend emerging, where more Australian instructors are ditching that ‘floppy bound handbook’ and replacing it with pages of checklists for the student to recite each time they jump in an aircraft; the student pilot deprived of the choice to either read – or to recall. And that’s not a good thing. Students should be armed with both techniques. To know and rely on mnemonics is the easiest and safest approach, in my opinion, with the prescribed lists there to read if operationally required, or deemed required by the PIC, or the operator.

For me, it proves that we are now teaching our future aviators to rely on something else – rather than themselves – in order to fly the machine safely and effectively. And disconnecting in that way goes against everything that I know about safe, single pilot recreational aviation. If there is no other team member(s) to rely on, and only you in the cockpit, relying on a computer screen or piece of paper may increase the chance of an accident and it will distract the single pilot from doing the first thing that instructors should be teaching them; to ‘fly’ the aircraft first, above everything else.

NICHOLAS CHRISTIE started flying lessons at the age of 13. He holds both Grade 2 (GA) and RAAus Flight Instructor ratings. Since graduating from Monash University with a Bachelor Business Management (Marketing), he has held various sales, marketing and management positions across a broad range of sectors. Nicholas has written for a variety of aviation magazines in Australia and currently runs his own aviation businesses. In 2016, Nicholas took on the challenge of building a “slow build” Van’s RV-12, at Tyabb (Victoria) and he has since become an active member of SAAA, AOPA and RAAus. Nicholas believes that the passion and involvement of people (especially youth) in the aviation community is key to the sector’s future success in Australia and that minimal government regulation will assist in the industry’s continued growth and success.

Tyabb VIC 3913, Australia

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