NASA made a study of errors made on the flight decks of airline operations. Of 60 flights observed eight hundred ninety-nine deviations were observed (194 in checklist use, 391 in monitoring, and 314 in primary procedures).
The captain was flying on 37 of the 60 flights and the first officer on the other 23.
The executive summary.
Checklists and monitoring are two essential defenses against equipment failures and pilot errors. Problems with checklist use and pilots’ failures to monitor adequately have a long history in aviation accidents.
A typical airline flight requires a great number of routine flight control inputs and switch actions and frequent reading and verification of visual displays. Many of these actions are governed by formal procedures specifying the sequence and manner of execution, after which checklists are used to bolster reliability. Throughout the flight, pilots are required to monitor many functions, the state of aircraft systems, aircraft configuration, flight path, and the actions of the other pilot in the cockpit. Thus, the number of opportunities for error is enormous, especially on challenging flights, and many of those opportunities are associated with checklists and monitoring—themselves safeguards designed to protect against error.
Our study was conducted to explore why checklists and monitoring sometimes fail to catch errors and equipment malfunctions as intended. In particular, we wanted to: 1) collect data on monitoring and checklist use in cockpit operations in typical flight conditions; 2) provide a plausible cognitive account of why deviations from formal checklist and monitoring procedures sometimes occur; 3) lay a foundation for identifying ways to reduce vulnerability to inadvertent checklist and monitoring errors; 4) compare checklist and monitoring execution in normal flights with performance issues uncovered in accident investigations; and 5) suggest ways to improve the effectiveness of checklists and monitoring.
https://human-factors.arc.nasa.gov/p...010-216396.pdf
Had a personal issue with the gear during training, instructor had me demonstrate slow flight (gear, flaps, speed brake) and then asked for a penetration. Nosed over for the penetration and wondered why the aircraft wouldn't accelerate to penetration speed with the aircraft in a seemingly vertical dive. Yes, things left hanging in the breeze, didn't even get to exceed any flap or gear limit speeds.
