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The necessity of following checklists can be traced all the way back to October 30th, 1935, where on that fateful day a B-17 Flying Fortress crew forgot to remove the gust locks before takeoff. Ater rotation, the plane immediately pitched abnormally nose high, stalled, and then crashed into the ground bursting into flames. Investigators determined that despite the crew’s obvious oversight, the real underlying cause of the accident was that the plane was simply too “complex” to fly due to the sheer number of preflight tasks required from memory. The solution? Boeing introduced the concept of the “checklist”, and the rest is as they say history. Yet despite their simplicity, I still find most checklists devilishly hard to use.
Ironically, despite my reverence for the POH, I have never followed any of its checklists—most flight schools and clubs typically have their own abbreviated checklists to adopt, which though loosely based on the POH, are more tailored to their own operation policies and procedures. Regardless, both the POH and checklists based on it usually violate good checklist design; they were written decades ago by lawyers who were more concerned about liability claims than efficacy. These checklists are typically long, tedious, and rarely make practical sense when you try to use them in the cockpit.
Concocting your own checklist is no easy task either as best-selling author and surgeon, Dr. Atul Gawande, outlines in his book, Checklist Manifesto: How to Get Things Right. In it, he describes his own struggles in adopting a checklist for surgical procedures and even goes so far to visit Boeing to better understand how checklists are created, vetted, and improved. A few key takeaways from his book are that every good checklist is concise, covers only critical tasks, and is meant to trigger whatever standard-operating procedures (SOPs) it is describing. In fact, there is a direct relationship between the checklist you use and the SOP you adopt. One reinforces the other and if they are out of sync, your checklists start to lose their efficacy.
Also, a good checklist will have a certain flow to them that becomes natural to follow over repeated use. One misconception I had was that checklists should be exhaustive—just the opposite is true. Trivial or non-critical tasks should not be on the checklist but rather be accomplished out of habit and are often triggered by critical ones. For example, turning on the fuel pump on a low wing piston before takeoff is critical and could also act as a triggering point to turn on the landing light too. One follows the other.
A good checklist will have a certain flow to them that becomes natural to follow over repeated use.
I find it fascinating that checklist “theory” isn’t really part of primary training outside of being told to blindly “follow the checklist” without really being taught how! As you are probably aware, checklists generally come in two flavors: READ-DO and DO-VERIFY. Most pilots fall into the latter category so if a checklist was written with the former in mind, following it can be a real struggle and vice-a-versa. That’s why a third-party checklist handed to you might prove to be borderline useless in the cockpit. Furthermore, most checklists at a professional level aren’t read, but verbalized by the flight crew—audio cues become triggers for actions and even help us verify those actions have been completed.
As a Part 91 operator, this begs the question then how do we get better at building and following checklists? I think some of the focus on checklists in early training is somewhat backwards—what we really need to do is engrain the use of SOPs and then build checklists that reinforce them. That way, following the checklist is more of a reflex than a conscience thought. As an example, if you standardize your “GUMPS” check every time you enter the downwind, the pre-landing checklist is already primed in your mind. But a checklist without an SOP behind it makes checklist usage more of a chore than a value-add. And I think that is where the slippery slope of complacency begins with having a slew of checklists in the cockpit to follow but never actually wanting to follow them.
Checklist usage shouldn’t feel like a chore, nor should it feel mandatory (and from a regulatory standpoint, it isn’t), but rather an act of habit. And the quality of checklists you use is directly responsible for how often you use them! Because once checklist usage feels natural instead of premediated, you don’t have to think about it anymore because it’s just part of flying—positive rate, gear up!
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Good article, but it is lacking one essential item: an example of a POH checklist (perhaps the Before Takeoff Checklist) compared with one of the type that you advocate. It is in the same vein as “a picture is worth a thousand words”.
Absolutely. The POH still is the definitive reference in which all of these checklists are ultimately based. I also forgot to mention that the SOPs you build for one plane are most likely transferable to another in some form or fashion too.
Thanks Alexander for addressing what’s obvious about checklist usage in light GA (single pilot) operations – it doesn’t work as we are using them, and for too many pilots this allows them to consider a checklists as a “chore” versus a tool to help them live to fly another day no mater what the conditions.
Imagine transport aircraft operations without a checklist – I can’t. They are so fundamental to operating complex aircraft and I believe it is the sing-song cadence of the PM reading and the PF responding to the core elements covered that is core to it’s effectiveness. Read any report about a transport crew experiencing a problem and in the recount of the event – the crew leveled the aircraft, ran the appropriate checklist and returned (or continued) to a normal landing.
Transport aircraft systems are complex, yet getting simpler; two pilots can fly a B747 anywhere in the world (within flight and duty time limits) and the lawyers have signed off on it! Light GA aircraft are getting more complex and we have multiple generations or pilots who consider checklist unimportant to their flight. How many light GA pilots have lost the one alternator on their one engine aircraft while inflight and failed to run the alternator failure checklist which would have helped them preserve the battery by eliminating the draw of the alternator on the battery, because they don’t know when and how to use a checklist.
A lot could be done to make checklists easy for the single pilot. ForeFlight allows you to edit and organize a checklist appropriate to your aircraft, and then it will read it to you. Also, making a list of the items to check, without using the space to suggest the answer has a lot going for it, and I have seen a list written out in linear text format used to great effect with a pilot doing the required elements of the check and then reading this “text”. Imagine what effect it would have on the industry if the POH/AFM had on page one in large bold print – There is nothing in this manual that precludes good airmanship, releasing us from the legal constraints that perpetuate poorly written checklists, and the usage that follows.
Herv, you nailed it! Particularly, that last sentence tying checklist usage to airmanship. I couldn’t agree more!
I always thought it was mandatory to use the POH checklist. Didn’t know you could make your own. Sure would be more user friendly!
Great article, thanks.
Often the COTS or personally developed checklists are much better/more useable than the manufacturer’s checklist, for your reasons stated. However, before developing your own, read SAFO 17006, and ensure your checklist covers all pertinent information.
Also consider writing in “pilot” terms showing pilot actions rather than engineering terms. Say throttle “forward” or “aft” rather than “open” or “closed,” xx switch “up” or “down,” etc., especially for emergency checklists.
I teach to consider accomplishing a checklist act whenever you “Move the Throttle” (I.e., throttle back at level off = check engine instruments, aux fuel pump, trim, mixture. Throttle back to start descent = fuel on desired tank, radios set (AWOS/CTAF), Engine checked (mixture reset, fuel pump), heading set, altimeter set, etc.)
I find the laminated cards for complex aircraft difficult to use. It is to easy to gloss over a line, or skip it completely. When I got my type rating in the Honda Jet, I loved how the checklist is on the screen with boxes you click as you do them. So for my current aircraft, I made a similar electronic checklist in Foreflight. I was able to add my own items for things I need to remember (like making sure the boots are off on the climb before the temp gets to -40C, and canceling IFR as part of the shutdown procedure).
You bring up a really great point about checklists being literally part of your workflow *in the panel* itself. This goes with Eric P.’s comment about “moving the throttle” to trigger a checklist/SOP.
After reading your narrative, I modified my check list. I enlarged my font, and now I don’t have to squint to read it. I have a laminated 8.5×11 sheet of paper. Less likely to misplace it.
It’s the little things, right?
A Swiss pilot, Captain Emil Wick, flew PC-6 (Pilatus Porter) for many years in Nepal. This was for the Royal Nepal Airlines. He was an instructor and also had an aircraft maintenance license too.
Before landing checks had four items to be read out. He always opened the checklist and read them. He never did checks from memory.