Checklist Fatigue

How much is too much?

“What are the after-takeoff checklist items?” I searched through the checklist to find the exact ones… meanwhile…“Watch your heading, maintain altitude”

As I took my eyes off from the panel to read the check list, of course I had drifted off course and deviated from my assigned altitude. As I transferred my attention to correct my course and heading, “Brief the procedure, what fix, initial or final, what heading,” snapped the next command.

This time I pulled my iPad up and tried to bring the procedure. It wasn’t sufficient that I review the key steps. Each time I had to read out the name of the procedure, valid dates, check any NOTAMs and whether they were applicable, and so on. Meanwhile … “watch your altitude… watch your heading.”

I switched again to level-off at 3000 ft which was what I had been cleared for and tried to orient myself to the avionics in the aircraft. I had never flown this aircraft before. Each time I fly a new aircraft, it does take a little flying to familiarize and get comfortable with the controls and avionics panel. As I tried to re-orient, “What are the cruise checklist items?”

 This time I pulled the cruise checklist to read the items of the list: “What is before that step… You need to read and confirm every one of them…”

I looked down, and repeated the one that I had thought was unnecessary to repeat… “Watch your heading… you are off course…”

I switched back yet again between checklists, cockpit familiarization, maintaining smooth control, procedure briefing from the iPad, and occasional communication with ATC. “How will you enter the hold …”

I switched to the iPad again. At this rate, I almost missed the days when I was using paper flight procedure plates. At least that was easier moving from departure procedure to approach procedure at a different airport.

And so, the flight progressed. Mostly VMC, going in and out of clouds. Wearing foggles limited my view of the outside, although I could see the occasional clouds as we pierced through them, vectored and rerouted by ATC to steer us away from other IFR traffic, and traffic advisories about VFR traffic in the vicinity.  Weather called for broken to scattered clouds at 4,000 ft at our departure airport and along our route. We had departed on an IFR flight plan with the intent to shoot some precision and non-precision approaches, holding and other required maneuvers for an Instrument Proficiency Check (IPC).

During the early days of flight, it was mostly seat of your pants flying. Airplanes had few navigation and flight control systems, and pilots mostly relied on their senses to gauge position and performance, and make decisions. Much of flying was by feel, intuition and experience.

In 1935 that changed. A B-17 Flying Fortress crashed after take-off when pilots failed to release a new rudder and elevator mechanism. After that event, checklists became a standard issue with an aircraft. As aircraft complexity increased more checklists were added. The 1990s saw the emergence of electronic checklists. Introduced in 1996, electronic checklists continue to be ever changing as technology evolves.

Initial checklists were made for completing routine procedures. A study issued by the FAA’s Commercial Aviation Safety Team [1] indicated that insufficient depth of system knowledge and/or over-reliance of automated checklist systems could lead to problems when managing unspecified failures. If the solution for every problem is another checklist, cognitive skills begin to diminish as critical thinking becomes unnecessary.

According to Flight Paramedic Dave Weber of Intermountain Life Flight in Salt Lake City, Utah [2], aviation and medical communities have reached a critical threshold with checklists. He suggests that we can’t make checklists for every part of our environment. Education and training are key and those items need to be trained and memorized. In his words:

“We’re seeing rapid skill diminishment across all fields when checklists are substituted for judgment. Critical faculties wither quickly once judgment is discouraged, and people are now becoming paralyzed when the problem doesn’t fit the checklist. They can’t process past that point in the checklist if there’s a problem mismatch.” [2]

Weber suggests checklists should be designed as reminders for experts who already know how to perform the tasks, not as “recipes” for beginners who are trying to use the checklist to figure it out. Weber’s solution for “checklist absurdity” is to streamline checklists down to include only the highest-risk procedures, and then edit those checklists to consist of five to nine bullet points.

I had never seen this drastic use of checklists before in my more than 20 years of flying. I have had my share of flying with different flight instructors in the course of that time either for flight reviews or advanced flight training. Many a time I have enjoyed these in depth flight reviews with my favorite instructors [3]. I had even done an IPC in the past. While every instructor has different techniques, this absurd adherence was almost negating the real reason why checklists are used in the first place: safety.

Good flight instructors are rare to find. Good flight instructors pay attention, adapt and train their students according to the situation, and student needs. No two students are the same. Further, every student is different. Not only in how they learn, and how they process and digest information, but also in the purpose and goal of their flying. While checklists are an essential part of flying, they need not be used to this level of absurdity.

I almost felt nostalgic for the good old days when flying was carefree and fun, and pilots were not bogged down by checklists.

Yep, the days of seat of your pants flying!

See Also:

  1. FAA: Commercial Aviation Safety Team: Operational Use of Flight Plan Systems
  2. AINOnline: Checklist Creep Adds Complexity
  3. Flynthings – BFR: It can be fun!

1964: An Aviation Pioneer is Honored at a Rose Garden Ceremony — Transportation History

May 4, 1964 Geraldine “Jerrie” Mock, less than three weeks after becoming the first woman to fly solo around the world, was awarded the Federal Aviation Agency’s Decoration for Exceptional Service by President Lyndon B. Johnson. This presentation took place in the Rose Garden at the White House. The 38-year-old Mock, in circumnavigating the globe […]

1964: An Aviation Pioneer is Honored at a Rose Garden Ceremony — Transportation History