Procedures and Checklist usage within GA

[Globalstream]

I didn't want to hijack Hawker750's thread on the value for money that Netjets provide (I think they do as a fractional service provider), but during the course of that thread there were some comments made regarding the virtues of airline style procedures and their applicability in the biz jet world. It's a bit of a hobby horse of mine and I wanted to discuss that further and make clear my points because I think it's such an important discussion.

I have an airline and biz jet background with a good part of that time spent as a FI, TRI/TRE AND SFI/SFE. I have trained and tested dozens of students, clients and colleagues, probably several hundred in all.

In my opinion, the most pressing safety issues for business aviation specifically are poor procedures and operational practices. Technical (eg aircraft) and systemic (eg ATC) improvements are generating consistently successful outcomes in routine flying that mask the lack of ability/procedural effectiveness of the backstop- the crew. Ironically, this can foster a false sense of competence in many operations.

Why do I think this? Because in the simulator we can generate those unfortunate circumstances that seem to align when an accident occurs and that often highlights flaws in procedure and discipline. This is especially unfortunate since SOPs are even more important for GA crews given their exposure to highly variable operating environments and conditions.

Consider a complete electrical loss after an instrument night departure from an airport in mountainous terrain. Jackson Hole Wy comes to mind

My experience in the simulator shows that even a relatively straight forward failure (a single failure for which a checklist exists) can overload a disturbing number of crews when realistic elements are added and it clearly shows procedural weakness.

Some commentators, confirming what I've seen on the line and in the sim, said they brief the initials and express a contemptuous attitude to further briefing. I can assure you that failure of the the electrical system or another event that requires hand flying part of the procedure at an inopportune moment, often results in a good deal of humility because despite the cursory briefing, crucial information was omitted or not understood.

Notes need to be read AND UNDERSTOOD, as does the routing, altitudes and speeds.

My experience training has only reinforced my belief in the effectiveness of "airline" style flows, checks and procedural discipline. When the chips are down, our perceptual field narrow tremendously and good procedures, drilled to become second nature (especially the processes for handling emergencies) make all the difference. They also facilitate speed and safety in normal ops.

Whenever I've encountered reluctance to discuss or implement SOPs, it usually seems to stem from ignorance (not having trained and operated with strict, but effective SOPs) and/or inappropriate defensiveness.

To be honest, applying the acid test as a trainer or examiner- would I let my friends and family fly with this guy? I find lazy, poor checklist usage infuriating. I have to blame generally weak biz jet training, but excuses for lack of them after "crashing" and a fair critique I just find appalling.

Now, getting biz jet manufacturers to produce airline style checklists and establishing reasonable methods to have check lists and SOPS approved by local authorities is another topic. I should also say my extolling of airline style procedures is in no way an endorsement of all airlines, many of whom, IMHO, have deep flaws of their own related to a broader decline in pilot development.

[CL300]

your view summarize it all.. Facts are that with the very low numbers of hours that bizjets are genrally flying, odds to encounter a very serious incident is low. However, when it arise, issue is quite often fatal.
What is missing the most in GA environment is a solid foundation on "why do i have to do it" eg Philosophy of the procedure. Asaf Degani wrote a very good study on the 4 P's of a checklist, and i can only urge anyone to read this study before committing himself (or herself) into a difficult corner of understanding the logic of the sop's.

[deefer dog]

My experience in the simulator shows that even a relatively straight forward failure (a single failure for which a checklist exists) can overload a disturbing number of crews when realistic elements are added and it clearly shows procedural weakness.

Some commentators, confirming what I've seen on the line and in the sim, said they brief the initials and express a contemptuous attitude to further briefing. I can assure you that failure of the the electrical system or another event that requires hand flying part of the procedure at an inopportune moment, often results in a good deal of humility because despite the cursory briefing, crucial information was omitted or not understood.

I'll play devil's advocate.

I understand the point you are trying to make here, but it seems that you are implying that all possible scenarios should be briefed prior to any departure, and this is neither practical or effective.

The question should surely be "what are the essentials that need to be briefed?" You highlight check list items, but surely the red line memory items should already be in the mind of a professional crew. Why therefore regurgitate these, and where do you stop? Is it necessary to go through the entire emergency or abnormal check list, and include this in your brief - I think not!

Obiouly both crew members need to be acquainted with the expected departure flight trajectory plus a small number of relevant "what ifs." In a mountainous region it would obviously be appropriate to discuss escape routes and MSA's, but in Holland for example this would be wasted breath. On a short wet runway it would be appropriate to pay more attention to the reject, and perhaps skip over this when departing from a long dry one.

The brief needs to be tailored to circumstances and kept short and sweet in line with the KISS principle. None of us know what will happen once we pass 80 kts., and all that should be done is to prepare for the scenarios that are likely to have the most adverse effect when considering the circumstances. Churning out check list actions for every possible eventuality won't help anyone - even if every checklist action was later called for!

[Joe le Taxi]

Great stuff-really pleased to see this come up.

I 100% agree with Deeferdog that briefs should be short and serve a real purpose, tailored to the venue and day. It is human nature to not pay attention when the other guy endlessly regurgitates the standard brief.

And I 100% agree with globalstream that the key to good crew co operation and workload when unusual things happen, is cockpit flows and ultra concise checklists.

Unfortunately and as you say, so much depends on how enlightened the ops inspector is. I had a Chief pilot who put a huge amount of effort into producing airline style flows and checks, but it was ruined by an idiot inspector from the dark ages who demanded he add a mass of non- essential junk to the procedures and checklists. Conversely, elsewhere we had an inspector who advocated just briefing stuff that was special about the day which could get us into trouble, and checklists which likewise, just covered essentials; the non essentials covered by flows.

[INNflight]

An input from an airline-damaged good (myself), if you don't mind.

I agree a lot of information can be an overkill very quickly, and it's easy to forget things, especially when the take-off briefing was done some 15-20 min prior the actual take-off.

However, from my point of view, the most important part is, if the proverbial s**t hits the fan, you need to know:

- where do I go and how do I get there
- how high do I need to go to be safe (MSA, obstacles, etc.)
- what do I do when I get there

We split the briefing into three parts, which is:

- minor malfunctions during take off (master cautions, etc.)
- performance-related (usually engine failure) and
- emergency case (fire, smoke,...)

Scenarios such as a complete electrical failure are usually not discussed, because that's all checklist work, and checklists rank behind flying the plane and navigating. As long as you know where to go and how high to go, you're safe, whether you have a caution or a major failure.

I don't want to be branded as the SOP-monkey (which no doubt I may be), but a standardized briefing and certain SOPs should be part of every flight, because when things turn ugly, there's usually no time to discuss them.

[sevenstrokeroll]

I have to admit I am not a fan of ''flows''. I prefer a "do list" with checks.

It might take a bit longer, but you are more likely (if doing it properly) to have all the switches etc inthe right place. (correct place ;-))

I've seen people do ''flows'' so fast that the relays can't keep up and mx gets called.

Slow and steady wins the race...esp when at the gate.

I've done lots of night instrument mountainous area departures...and having that flashlight in my pocket, to be placed in my mouth if needed to aim at critical instruments was the way to go.

I do offer this...while instructing in GenAv 30 years ago (airline now) i noticed some students couldn't get "INTO" the simulation...it wasn't real...and they sat there and did nothing.

I asked them why and they just couldn't. It was like: my instructor is trying to fool me, it isn't really happening.

I do favor rote...over and over until if you sneeze the right checklists come out.

I do think we will see MORE and not LESS bizjet crashes in the years ahead.

[BizJetJock]

It might take a bit longer, but you are more likely (if doing it properly) to have all the switches etc inthe right place. (correct place ;-))

Unfortunately this is just not true. Airlines, manufacturers and NASA have spent millions on research and found that "read and do" checklists have a higher incidence of mistakes, usually by skipping an item inadvertently, than a properly executed flow. I agree that hands flashing around the cockpit at high speed is a nightmare, but that is not a flow; that is someone being stupid.

The question should surely be "what are the essentials that need to be briefed?"

I agree entirely; unfortunately the whole problem is that it is usually not asked. A lot of the problems come from pilots not actually thinking through what is required and then doing a "standard" brief (if they do one at all when an instructor isn't watching) even when there are non standard items that need attention. The overkill response to this from some companies is the "brief everything" approach which is no better. And I won't even start on the people who brief something completely different from how they are actually going to fly it - normal or emergency.
Unfortunately a lot of the problem is laziness. Without a disciplinary threat from a large organisation hanging over hem, people don't bother to practice the flows and procedures to the point where they are proficient, skip over them in the interests of a perceived few seconds time saving. They then justify this by dismissing it as "Airline bull****".

All a very long winded way of saying I agree entirely with Globalstream.

[FrankR]

I believe your comparison between Business jets and airlines is misaligned. You refer to business jet pilots adopting “Airline style checklists” and the “virtues of airline style checklists” What exactly is the difference you are talking about, and how does an airline checklist differ from my private flight department checklist? Mind you, I sat in a G550 and a BBJ last month and ground through both checklists, and found little difference between the two other than the Boeing was laminated and the Gulfstream was a clever electronic one.

You talk about “Airline flows” as if they are unique to Airbus or Bombardier or Boeing (but not the business jet side I guess). Gulfstream has been advocating the “Flow then checklist” method for years, as most airlines do, since it insures you have two chances to catch an errant switch position. Does anyone advocate any other method???

You stated:
“In my opinion, the most pressing safety issues for business aviation specifically are poor procedures and operational practices”. I'm with you, but following known procedures and practices has to do with integrity and discipline, not checklist procedure or an ALPA card.

What's the most pressing safety issue for airlines? I find that sloppy pilots, who lack situational awareness, who ignore the regs, and who fly aircraft that shouldn't be dispatched can be found equally on both sides of the taxiway. “Management” and “Safety-checks” in the airlines can just as easily turn into coercion of flight crew and reduce safety. We can agree on one thing, I'm just as infuriated by lazy avoidance of procedures.

As for discussing SOPs, my opinion is that when “us business jet” pilots are reluctant to discuss SOPs, it is because far far too often, these changes are coming from a new chief pilot, (who has no manners and often just washed out of an airline environment) and who has some outlandish idea, which often is tedious, adds nothing, and contradicts common sense or regulation. For example, the latest change I fought against was the adoption of a standard callout “20,000 Ft. above touchdown”. Talk about absurdity!! I sure this comes from an airline.

Doing what you say you are going to do, and have been trained to do is called integrity, or lack thereof.

Sorry, but I've never seen the NTSB state that "A properly approved airline checklist would have prevented this accident"

FR

[gigi116]

It's a bit of a hobby horse of mine and I wanted to discuss that further and make clear my points because I think it's such an important discussion.

Fully agree with you ! I believe some problems arise from lack of proper documentation from BIZJET Manufacturers :

They offer AFM / POH / QRH full of notes for different types of avionic / modifications/installations and lot of AFM supplements.

No FCOM, No Real Check lists and No SOPs available.

Docs are often structured and printed without any regards of Human Factor ICAO standards and the term "checklist" used improperly to indicate "procedures".

Usually the Operator does'nt want any responsability / problems with CAA and copy those " procedures" on a plastic sheet pretending the use as "check list".

Results are long check list full of items not considered "critical" and items often left "to go" during Check List reading (eg. APR armed during take off roll or yaw damper off during landing).

The CAA is happy because it is a Manufacturer Check list !

[gigi116]

have to admit I am not a fan of ''flows''. I prefer a "do list" with checks.

My opinion is that DO LIST (Read and Do) is not applicable for After Take off and Before Landing check list whereas PF call for gear and flap and then both verify using check list as follow up !

Accomplishing DO LIST in other phases may require to hold until item (e.g test) is completed and this wait increase the probabiliy of mistakes (or errors)!

In my Company DO LIST is only for Abnormal / Emergency.

[sevenstrokeroll]

one of the things I've noticed is that when a company is expanding (or contracting), there is a great deal of changing equipment as new bids come out.

someone who has flown a plane for years...flows...its natural...but when you do change equipment...things just aren't as ready and easy...

[elvis82]

Thank you for this thread.

That's why we are a professional pilots. When we fly the airplane for 3 to 60 mio $, it is just expected we know it well and we know well how to push buttons and in what order and why. That's why it is called -check-list. According the PANS OPS, the check list should include only safety related items which when omitted could cause a dangerous situation - gear, flaps, altimeters check, etc. For example if you forget to switch the landing light on the take off/landing or even switch on the engine syncrophraser after take off, nothing will happen (why you shoud forget do this, when you are doing it on every flight?). I flew both business jets and airliners. Altough I just love bizjets, the difference was obvious. I soon recognized, that doing Do list on take off or taxiing is not a good idea! It is also exhausting doing the Do list on the 4th or 5th leg! This AOC operation was approved by CAA, it is real supervision, isn't it?!

The procedures from the bizjet makers are just horrible. There are a lot of chief pilots in the bizjets environment who just do not understand the problematic of proper use of checklists! They do not even know what the PANS OPS is. Company can do its own normal checklist which should with connection on SOP be done in accordance the manufactures procedures. But you are not obliged to use Cessna Citation checklist, where it is written in the Take off checklist that you should pull up!!! And the CAA is not providing enough support on that. I have experience that when you do any SOP, they just accept it.

As I said, I love bizjets, but there is from many reasons poor safety environment. If I had money and wanted to fly as a pax I would really fly with NetJets or airlines in the first class.

You can still fly bizjets according the procedures that are widely used in airlines like for example NetJets Europe or some other companies. It is better then crossing hands in the cockpit while doing Do list. I saw it and this was just horrible.

These procedures are only part of problem of bizjets safety. There are other issues for another threads (training, pilots selection, supervision, skills and knowladge). I am not able to compare maintenance quality of bizjets and airliners.

[tommoutrie]

this is like Top Gun. Have we worked out who the best pilot is yet? Ice Man from the Airlines or Maverick from the Biz Jets?

crashing planes is down to CRM, poor airmanship, inexperience, complacence, overbearing management, and loads of other things that we all know about but I doubt its ever because of a poor checklist. I fly with a manufacturers checklist because we choose to minimise the retraining element of an OPC by making the SOP's exactly what the manufacturer says they should be. There's a bunch of changes that we could make to what Bombardier say that may make things easier or safer but nothing thats in the checklist stops us from exercising the best airmanship that we are able to and that is our best protection against incidents and accidents. And should there be an incident of any kind, doing what the manufacturer says is pretty iron clad when you go to court.

[Globalstream]

Tommie, I don`t think this is at all about ego. It`s a real problem that warrants proper discussion.

All, I think some have a misunderstanding of what exactly an "airline style" checklist is and how it is used. A properly developed checklist is concise but complete, easy to use and most importantly relavent, preferably tailored, to the operation. Hawker750 mentioned completing briefings prior to engine start are part of his SOPs. Perfect example

However, SOPs and checklists have to be developed, implemented, trained and checked and refined on an on going basis and that done, they invariably makes things safer, faster and more efficient.

Any checklist/SOP that results in rambling, incoherent briefings, confusion regarding timing and division of checks and interminable checking is poor. Separately, we have to differentiate between poor SOPs and poorly executed SOPs.

Poor checklists are hallmarked by poor formatting (often with errors or weak points), repetition and a stuccato flow. Combined with a lack of training and direction this results (in my observation) in stuttering, inconsistent and incomplete usage. Many crews I have worked with seemed not to have any clear idea of who should call items, when they should be called (if specific) or the proper response. Take just one example- spoilers.

In the simulator I set a fault that prevents the spoilers from arming. It will not result in a fault light/CAS message, but the arm indication fails to illuminate. The manufacturer`s checklist says "Spoilers- Armed". Often, the FP selects the lever to arm and calls armed without checking the corresponding light on the annunciator panel and so misses problem. The MP is head down speed reading the challenges, possibly responding himself and rushing because of the poor time planning on the part of the FP. He also misses the light...as they approach a short, contaminated runway.

Neither demonstrate understanding, or at least neither is demonstrating the need to set AND CHECK the result- a fundamental point of checklist usage and indeed, airmanship.

Regards reliance on manufacturer`s checklists. Understand first, in no way am I advocating using ad hoc, unapproved procedures and I have only worked with two brands in my biz jet career and so I can`t comment on Cessna, Hawker and so on. (Frank, Boeing checks and philosophies, Gulfstream`s too are not really representative of the smaller biz aircraft I am thinking of)

However I can think of one check list in particular that renders the manufacturer liable IMHO, should an accident result. I am not a lawyer, but I`m not sure I would bet my life or career on implementing manufacturer`s checklist without thought. Especially if I was in charge of a commercial operation.

Anyway, check lists and briefings and are but one aspect of professional SOPs and I stand by my assertion that only tailored, properly trained and checked SOPS can maximise safety and efficiency.

[733driver]

tom, I must admit I tend to agree more with elvis here. I don't see it as a top gun fight (who is the coolest).

Most GA manufacturers are just not good at producing checklists. They put a normal procedure in a ring book and call it a checklist. My favourite example is the "go around checklist" on most bizjets. It goes something like this: G/A thrust,Pitch up, positive rate, gear up, 400ft flaps up etc. That's not a checklist. That's a procedure. By the time you have a chance to read it it's too late.

Also the cockpits often aren't designed to facilitate flows and the published procedures and checklist don't allow for them.

Why do you think it is that almost everyone who has flown both (airlines and G/A) thinks that airline checklists are better? I think it is mainly because of the manufacturers and the quality of their documentation, not so much the operators or pilots.

Good procedures and checklists do not equal long checklists by the way. The opposite is the case. Flows allow you to do the switching at the appropriate time (phase of flight) and then confirm at an appropriate time by checklist that no essentials (gear, flaps, altimeters etc) have been missed. This is usually quicker and safer than the old read-and-do way of doing things. In fact, when it comes to the landing checklist for example: When do you guys lower the gear? Or extend the flaps? When the checklist tells you to or at the appropriate time? So you do a flow with a follow up checklist, not a read-and-do. Why not use that concept for all of the flight (exept abnormals and emergencies)?

737 yoke checklist:

[Globalstream]

733driver

Excellent point regards the formatting. How infuriating to thumb through a "book" of 12 point in a cramped, poorly lit cockpit!