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informed ATC that we were descending while I flew the
aircraft. We were cleared to 11,000 feet. Upon further
completion of the checklist we discovered that the bleed
selects were both off. Selecting the proper position on the
bleeds solved the problem.
Interruptions to the preflight routine contributed to nonaccomplishment
of the Preliminary Checklist. I skipped
ahead to the next checklist in order to start the APU, and
forgot to return to the Preliminary Checklist. The most
effective method of preventing a recurrence is to not attempt
to do procedures out of sequence on the checklist.
Checklist Interrupted–Runway Excursion
A Challenger flight crew found that holding instructions
interfered with completion of the In Range Checklist.
■ Approaching the VOR, we were slowing for the approach
to ZZZ. I had started the ‘In Range’ Checklist, completing
most of the items on the list, when we received holding
instructions only 1-2 miles from the holding fix. By the
time I responded to ATC, we were nearly on top of the fix.
I interrupted the checklist to prepare for the hold. After
entry…we received a vector to intercept the localizer for
the ILS approach to ZZZ. The approach was completed
normally to touchdown. When we landed on the wet
Runway 26 at ZZZ, we attempted to deploy the thrust
reversers, which did not deploy. When I checked the
switches, the ‘unsafe to arm’ lights were on. It took a few
seconds to stow the levers and arm the reversers, but it was
too late. With the very wet runway and downhill landing,
we were unable to stop before the end of the runway. We
exited the end of the runway at a relatively low speed
hitting a runway end light…Arriving at the ramp, we
inspected the aircraft to find a slightly damaged right gear
door…
Upon reflection…it seems evident to me that I never
completed the interrupted ‘In Range’ Checklist, thereby not
arming the thrust reverse system prior to landing.
A Monthly Safety Bulletin from
The Office of the NASA
Aviation Safety Reporting
System,
P.O. Box 189,
Moffett Field, CA
94035-0189
http://asrs.arc.nasa.gov/
June 2006 Report Intake
Air Carrier/Air Taxi Pilots 2223
General Aviation Pilots 766
Controllers 83
Cabin/Mechanics/Military/Other 137
TOTAL 3209
ASRS Alerts Issued in June 2006
Subject of Alert No. of Alerts
Aircraft or aircraft equipment 8
Airport facility or procedure 2
Company policy 1
Company policy 1
Total 12
Meet the Staff
rate of descent. For whatever reason (luck, training, or
abject fear), I suddenly remembered that I had been on the
auxiliary fuel tanks and switched to the mains (which each
had 40 gallons in them). Both engines came to life just as
[airport] came into sight…
I will never again be running on auxiliary fuel when I
begin my descent. I will find a way to get through the Pre-
Descent Checklist no matter what happens…I am a fanatic
about checklists and yet, on one of those rare occasions
when I let my checklist scan fall through the cracks, it
almost cost me…
Checklist Interrupted–Gear-Up Landing
CALLBACK #292 (January 2004) noted, “Two factors,
distraction and preoccupation, are common to most of
the gear up incidents reported to ASRS.” Both factors
were present in this gear-up incident reported by a Lake
Buccaneer pilot.
■ I was on base leg to final when the second aircraft
called on the radio announcing their position on a practice
VOR approach. The approach was to Runway 23 and the
runway in use was Runway 05. I called the aircraft to
verify that they had me in sight on final. After the short
exchange on the radio, they continued to fly the missed
approach and I continued the short final approach to
a gear-up landing. Contributing factors: The radio
conversation and looking for the traffic approaching the
opposite end of the runway, interrupted my approach check
sequence…I should have extended my approach pattern or
made a go-around until conflict with traffic was resolved.
This would have given me more time to review my checklist.
Editor’s Note: Callback has previously summarized
important research on checklist human factors and
typography by Dr. Asaf Degani of the NASA Ames Research
Center. These studies are available on Dr. Degani’s
HomePage at http://ti.arc.nasa.gov/people/asaf/index.php,
under the link for Procedure Development and Design.
Fred “Fast Freddy” Lohden
　
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