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Copyright 2023 Patrick Mullane, All Rights Reserved

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Chapter 8
Checklists: Cool Pilots Use Them

 

On May 31, 2014, a Gulfstream IV business jet taxied to the active runway at what would later become my home airport—Hanscom Field. Onboard were two crew, one attendant, and four passengers. One of the passengers was the co-owner of the Philadelphia Inquirer newspaper. 

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At 9:39 pm local time, the airplane rolled onto Runway 11 after being cleared for takeoff. The pilots pushed the throttles forward. The plane gained speed. At about 3,000 feet down the 7,000-foot runway and at about 126 knots, the copilot said, “Rotate,” indicating to the pilot it was time to pull back on the control column and guide the aircraft into the air. But the plane didn’t get airborne, even as it continued to accelerate. With just 1,000 feet of runway left, the plane was still on the ground and doing 162 knots (186 mph). The pilots were unable to stop the Gulfstream. It exited the runway into a field beyond the runway runover area before crashing into a line of trees and a gully. The plane caught fire. Nobody survived.

 

The crash was a perplexing one. Airplanes with a lot of airspeed and a little back pressure on the yoke usually want to fly. The wing can’t help but do it … the laws of physics work and are consistent. What happened?

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Before answering that question, let me tell the story of another crash. In 1935, Boeing was competing for a contract to deliver a long-range bomber to the Army. Their entry into the competition was what they called the Model 299. During a demonstration flight late in the selection process, the bomber prototype rolled down the runway, became airborne, but then stalled at about 200 feet. Way too low to recover, the plane crashed and burned. Two of the five people onboard died. Fortunately for Boeing, the tragedy didn’t prevent them from eventually being awarded a contract for the airplane. It became the workhorse of the U.S. bomber fleet and was known as the B-17 Flying Fortress, the aircraft my grandfather flew in during World War II.

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I’ve told these two crash stories because they were caused by the exact same thing, demonstrating that it’s very hard to keep history from repeating itself in aviation. In both cases, control locks (which keep the flight controls from banging around in the wind when the plane is parked) were left in place when the pilots initiated their takeoffs. While the mechanisms for locking the controls were very different in each instance, both their purpose and the effect of trying to take off with them engaged were identical. The only difference is that the B-17 was able to get airborne, the Gulfstream wasn’t.

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The B-17 crash woke up a growing aviation community to the risks related to flying more complex aircraft without some reference to standard procedures. The checklist was born.

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The unfortunate crash of the B-17 prototype perhaps can be forgiven. The pilots, after all, didn’t have a checklist. But the crash of the Gulfstream IV is a different case. They did have a checklist. And I’m certain something like “ensure flight controls are free and correct” is listed on it—and probably more than once. In fact, the checklist for the aircraft I flew at my flight school required a flight control check twice before taking the runway: once before engine start and then again right before takeoff. 

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While writing this book, Dale “Snort” Snodgrass, the man with more flight hours in the U.S. Navy’s F-14 Tomcat than any other human and a renowned airshow pilot, was killed in the crash of an aircraft he owned when it nosed up during takeoff and stalled before cratering into the ground in a classic stall-spin scenario. The cause? You have probably guessed: failure to remove a gust lock before takeoff. It was noted by those who knew him that he was a details guy and was methodical in his preflight procedures. But there’s evidence to suggest on the day of the crash he was in a hurry. Not taking the few seconds to rotate the stick in his aircraft in a circle to ensure that the flight controls were free and correct cost him his life. 

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I sound critical here. And to some degree I am. But as they say, “Pride goeth before the fall.” The sad truth is that even when the checklist is in my hand and I’m working through it, I’ve found it very easy to miss a step. I sometimes fly an Archer III, an aircraft that doesn’t have a key to select magnetos and engage the starter but overhead switches instead. I missed the checklist item that instructed me to turn on the left magneto before initiating an engine start; I cranked the starter with both magnetos—which supply energy to the spark plugs—off. Even if you’re very early in your flight training journey, you probably know this won’t work. 

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So, while checklists are critical to use, they aren’t foolproof, because you aren’t foolproof. 

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Walk-arounds and flows

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As you get more comfortable flying, there will be an inevitable desire to simply walk through the items on the checklist without really looking at them. This has much to do with the ritual of doing something the same way every time. In fact, it’s a bit ironic to consider that repeating the checklist over and over can make it more likely that you won’t want to use it at some point. For example, the preflight of an airplane is often called a “walk-around.” It’s not surprising why: you literally start at one place outside the aircraft and work your way around it until you are back where you started, checking items along the way. But after many, many run-throughs of the items on the checklist, the visual cues of the walk-around itself quickly take over and remind you of what to check. When I step off the wing onto the tarmac when exiting a Piper Cherokee on the right side of the plane (where the only door on the airplane is located), the first thing I’ll notice as I look at the wing is the right flap. And, not surprisingly, the first checklist item after checking the general condition of the wing is “Flap . . . Check.” After scrutinizing the flap’s condition and its linkages, I continue my walk along the trailing edge of the wing, coming next to the right aileron. I ensure it moves freely and its control rod and hinges look normal. Then to the wingtip. I continue this walk to the front of the right wing, the nose of the airplane, the left wing, and the empennage before ending up behind the right wing, right where I started. This stroll around the outside of the plane mimics the order of items on the checklist—or, more accurately, the checklist was written to match a logical flow around the plane.

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Knowing a flow, even without reference in the moment to a checklist, is a beautiful thing. But it should never be done without a cross-reference back to the checklist at some point. I’m to the point now where, after doing a complete walk-around without looking at the checklist, I stand in front of the plane right in front of the spinner and go through each item to ensure that I covered everything, starting with that “Flap . . . Check” item.  

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Flows aren’t just good for the preflight, they are exceptionally useful while in flight. You should in fact spend some time learning flows related to the many emergency procedures for your airplane. This is because some emergencies need immediate attention, so you won’t always have the luxury of pulling out a collection of checklists, finding the right one, and then methodically stepping through it. 

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There were two things I found very helpful when trying to get emergency checklists committed to memory as part of a flow. First, I found a schematic of my airplane’s controls and instrument panel on the internet and printed it out. I then drew numbered arrows from one control and/or instrument to the next to show their relative order of steps to undertake in a critical situation. For example, the “Engine Fire in Flight” checklist has five things to do immediately: 

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1. Fuel Selector . . . OFF

2. Throttle . . . CLOSED

3. Mixture . . . CUTOFF

4. Fuel Pump . . . OFF

5. Heater and Defroster . . . OFF

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On my schematic of the cockpit, I have arrows that run from the lower left of the instrument panel (where the fuel selector valve is located) to the throttle in the center console, to the mixture (also in the center console), to the fuel pump switch, to the heater and defroster levers. I then committed to memory the last two steps after these five: 1) initiate an emergency descent with speeds around 120 knots to get down quickly and (hopefully) put out the fire, and 2) prepare for an off-field landing. That diagram of my cockpit with arrows overlaying it was a visual that was easy to recall in my mind’s eye, helping me to know where to move my hands as I executed the checklist steps without even looking at it.  Again, though, time permitting you should always backup your flow by reference to the checklist after the fact.

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The second thing I did when it came to emergency procedure flows was spend some time not just memorizing the steps but thinking through why the steps are necessary. In the case of an engine fire, it doesn’t take a firefighter to understand that your priority should be to starve the fire of its fuel source. The best way to do this in most aircraft is to cut off the fuel flow from the tanks to the engine. Additionally, closing the throttle and cutting off the mixture ensures that any fuel that has already made it past the shutoff valve can’t be mixed with air in the engine, eliminating another potential fire source. Turning the fuel pump off keeps fuel from being delivered to the engine. Lastly, turning off the heater and defroster ensures that any smoke from the engine compartment doesn’t enter the cockpit.

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The Invisible Gorilla

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Even with checklists, flows, and mnemonics though, it is unbelievably easy to forget items on a checklist or forget the checklist altogether. In thinking through why this might be, I’m reminded of a famous experiment carried out at Harvard. In it, a group of subjects was shown a video of a ball being passed between six people arranged in a circle. Three of the ball-passers wore white shirts and three wore black shirts. Subjects watching the video were asked to count the number of passes between those in the video wearing white shirts. Easy enough, right? Well … yes, it is. But here’s the kicker: during the ball-passing, somebody wearing a gorilla suit walked into the middle of the circle, faced the camera, pounded their chest, and walked off the screen. When the ball-passing came to an end, those watching the video were asked if they saw the gorilla. Half of those who participated did not see the gorilla—which has since become known as the “invisible gorilla.” 

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How in the name of all that is holy is that possible? It’s truly perplexing. Search for the video online and you can find it. You’ll have no problem counting the passes and seeing the gorilla but, of course, you know about the gorilla ahead of time. The phenomenon exhibited by those who watched the video and didn’t see the gorilla while counting the passes is called “inattentional blindness.” In a paper written in Psychological Science, in 2014, the three authors (Drew, Vo, and Wolfe) define inattentional blindness as missing salient events in our world if we are engaged in a different task. 

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Flying is an activity where we are always involved in a “different task.” By this I mean you are almost always managing multiple workstreams. And when you are doing that, it can be easy to forget to refer to a checklist, employ a mnemonic you have learned, or check off a checklist item. I know … it’s happened to me. While building hours as a solo student pilot, I was approaching Hanscom for landing and had been given instructions telling me to enter a left downwind for Runway 29, the approach I was most familiar with as this was the runway used probably 80 percent of the time given prevailing winds. As usual, the airspace was very crowded with aircraft like mine—small, slow piston-driven planes—and faster, heavier business jets. I set up for a 45° entry to the downwind leg of the pattern as I was trained to do. 

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Just as I was about to come abreast of the numbers on the far end of the runway (i.e., the side opposite the end where I was going to set up for a final approach), the tower decided to change the landing runway to Runway 11. Given the complicated choreography required to manipulate a crowded traffic pattern into a new flow for a new runway, the tower asked me if I could do a short approach so that I could get on the ground quickly and get out of their way (they didn’t say this last part but in listening to the radio traffic it was clear that this was what they had in mind). I agreed, having done several short approaches during my training. For the uninitiated, a short approach is one where you have an unusually short final because you are turning base when you are essentially abeam the end of the runway. I immediately made a left turn and aimed just to the left of the threshold, putting me on a 90° intercept angle for the runway centerline. I had little time to get ready for landing. I put in some flaps to slow down and began a turn to a final that would have me rolling out of my turn on the centerline just as I was crossing the threshold of the runway. I got full flaps in and then greased the landing (as far as any of you know). I got off the runway as soon as possible, knowing that there was a Gulfstream conga line behind me.

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When I exited the active runway, I pulled out my checklist and proceeded to step through the after-landing items. When I got to the fifth item—Fuel Pump . . . OFF—I realized it was already off. And that’s because I had never turned it on during my setup for landing. It should have been turned on for redundancy. The airplane had an engine-driven fuel pump so turning on the electric pump during landing was a way to ensure that, if the engine-driven pump failed close to the ground, I wouldn’t find my engine quitting from fuel starvation. 

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While all turned out okay, in my own mental debrief of how I forgot to turn on the fuel pump, it became immediately clear how I had screwed things up. 

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Like many pilots, I use the BC-GUMPS mnemonic to set up for a landing. While there are mild variations on what each of the letters stand for, here’s how I define them:

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• B—Boost Pump; otherwise known as the fuel pump, on.

• C—Carburetor Heat; configured on or off depending on the aircraft.

• G—Gas; ensure you have selected a gas tank with gas.

• U—Undercarriage; is the landing gear down?

• M—Mixture; it should be full rich in most cases to ensure max power if you need it on a go-around.

• P—Propeller; this one is meant for those flying aircraft with constant speed propellers. Since I fly airplanes with a fixed pitch propeller, I instead let the “P” stand for “power”—I like to ensure the engine RPM is where I want it to be.

• S—Safety and Switches; are your seatbelts fastened? Landing light on? 

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I would usually conduct my BC-GUMPS checklist when I was midfield on my downwind. But the sudden change of runway and the sense that the controller was busy and really needed me on the ground to help sequence in faster aircraft made me behave like somebody counting the number of passes between the white shirts in the invisible gorilla experiment. I got so focused on one thing—completing a short approach to comply with the controller’s instructions—that I forgot my BC-GUMPS checklist even though there was ample time. It was my invisible gorilla in that moment. There was another factor that contributed to my inattentiveness. While, as I mentioned, I had completed several “short” approaches during my training, I hadn’t done them while also changing from one runway to another. The views were different, pattern abnormal, and there was a LOT of chatter on the tower frequency. All conspired to distract me from my normal flow.

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Don’t be a deviant

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The thing that’s tricky about checklists is that not only can they be easy to miss when you are distracted, but they can also be easy to miss when you aren’t distracted at all. The crash of the Gulfstream at Hanscom I discussed earlier was a “normal” takeoff by all accounts. But by normal, I don’t mean that everything was done by the book. Rather, I mean that the crew did what they had apparently done repeatedly in the past in a rote way. In the NTSB investigation into the accident, it was discovered using data from a flight recorder that the pilots hadn’t performed complete flight control checks on 98% of their previous 175 takeoffs. They weren’t distracted at all; they had just made as standard practice an improper behavior that hadn’t bitten them before. 

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There’s a name for this. It’s called the “normalization of deviance.” The term was coined by Diane Vaughan, a sociologist at Columbia University. Her term and the definition of it—the process by which deviance from correct or proper behavior becomes normalized in the corporate culture—became well known because of her book, The Challenger Launch Decision. In that book, Vaughan noted that engineers at NASA allowed pre-established safety rules to be violated when they found that violating them had no adverse consequences. With schedule and budget pressures at play, it became easy to implicitly and explicitly rewrite those rules of safety to continue launching shuttles with a known design flaw. 

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In the case of the Gulfstream crew at Hanscom, this is exactly what happened. The crew had gotten into a habit of not checking their controls before beginning their takeoff. From their perspective, it probably seemed unnecessary. After all, in every case before that deadly day at Hanscom, the takeoff proceeded without event. In fact, it’s entirely possible that at some point they simply forgot that it ever was a requirement to check the flight controls . . . although I must admit that this seems incredibly hard to believe—especially since checking flight controls takes virtually no effort at all, so why not do it? The other peculiar factor in this accident is one that is important for those of you who will be flying without a copilot—in other words, all of you. You’ll be required to fly solo before you get your certificate and will probably fly solo even after your checkride. The crew in the Hanscom crash flew together regularly. This seems to have led to a familiarity with each other that quite literally became deadly. I suspect that if the pilot in command when the crash happened had had a different copilot on each of the 175 takeoffs the data recorder captured leading up to the accident, most of them would have asked about checking the flight controls per the checklist. But since the pilots had normalized deviance together, neither one called out the other. It was as if the pilot in command was in the cockpit without a copilot—just as you will almost always be. What happened to this crew is relevant for you as a single pilot: you don’t have somebody to challenge you.

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So how do you ensure that you adhere to checklists and don’t slip into your own deviant normalizations? The best answer I’ve found is to—without fail—read your checklist items out loud and tell yourself you’ve completed them out loud as well … even if you are alone. There is some sort of self-accountability this drives. In effect, you need to, for a moment, have multiple personalities. I call my copilot personality Checklist Charlie. When I’m going through my checklists, I ask my alter ego if he has confirmed or completed the items I’m reading. I like to imagine my checklist buddy has a British accent like Lord Haldane but more youthful and without the patina of arrogance I imagine he might have had in his voice. Checklist Charlie’s accent is laced with cheer and enthusiasm. 

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Me: “Why my good fellow, Charlie Checklist, did you confirm that carb heat is off?” 

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Checklist Charlie: “Well I most certainly did Patrick.”

 

Okay, I don’t use those words exactly. But I do read the checklist items and respond to them with my own voice. If I’m with passengers, I warn them that I’ll be doing a lot of talking to myself. This helps put them at ease (I hope) and gives them a clue as to when the cockpit should be “sterile”—i.e., free of distractions like unnecessary conversation. I tell them that if I’m doing a lot of talking, they shouldn’t be. 

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The callouts to myself are accompanied by hand and eye movements that check the status of something or execute an action. This statement may seem like a “no duh” one: of course you have to move your eyes and hands to, for example, turn on your master switch. But it turns out this connection of verbal verification to motor skills is something that those who have studied checklists say is very important. In a paper by researchers Asaf Degani and Earl Wiener called “Cockpit Checklists: Concepts, Design, and Use,” the authors note the following: 

 

Besides visual verification of the check item, motor movements such as touching controls and displays (“muscle memory” as some define it), are also an effective enhancement for the verification process. The use of the hand to guide the eye while conducting the check can substantially aid the checklist procedure by combining the mental sequencing process with motor movements. 

 

I agree. In fact, I like to think that the combination of my own voice, the movement of my hands to execute the checklist item, and the movement of my eyes from the checklist to where my hands are going constitute a sort of three-channel system that is constantly checking itself. As you become familiar with your checklists, you’ll feel this connection between the three legs of your checklist execution system take hold. In fact, it will become awkward if any one of the three things don’t match for some reason. You’ll notice this if you fly one aircraft a lot and then transition into a new one where the location of, for example, the avionics power switch is not where you expected. You’ll read the item that tells you to turn it on, move your hand in the direction you expect the switch to be, and then look to find it’s not there. This is your “does not compute” moment and should force you to pause and consider what went wrong. 

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Make the checklist work for you

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Another thing I found helpful was to create my own checklist. To be clear, my checklist had all the same steps in the same order as the checklist the school provided to me and as the POH recommended. Why, then, create a new one? There are three reasons. First, there was formatting on the provided checklist that was meant to emphasize certain important steps but, for whatever reason, made it more likely I’d miss the step. It’s almost as if the most prevalent formatting locked my brain into looking for it and it alone at the exclusion of formatting meant to emphasize a point; the highlighted items, in some cases, became invisible to me. After several times missing such items, I decided to format it the way I wanted. Not only was the new checklist clearer for me to read, the simple act of changing it to my preferences put a bookmark in my brain related to the step; I was more likely to remember that I had changed a given step in some way and therefore less likely to miss the step.

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The second reason to modify a checklist is to make some steps more discreet. By this I mean that some checklists include two steps combined into one. On my school’s checklist for the Piper Warrior III, the “Engine Runup” section includes this:

 

Load meter, all lights, fuel pump, & pitot on .... check then off.

 

This is a check to ensure that the alternator’s output can match the demand of heavy electrical load before takeoff. I know it seems silly to many of you, but I often would read the first part telling me to turn on all the electrical systems and then forget the second part telling me to turn off what I had turned on. This was solved by creating two distinct steps: one to turn on the equipment and one to turn it off. 

 

Finally, often checklists would be better if things were added to them. Some items you may add are directly related to the safe operation of the aircraft. But additions can also be much more pedestrian. I fly with a ForeFlight Sentry ADS-B device which, when connected to an iPad, gives me real-time data related to my position and other air traffic (among other things). The Sentry is about the size of a deck of cards and is usually mounted to a window on the airplane with a suction cup. I have had a terrible habit of forgetting to retrieve my Sentry at the end of a flight, only to return home and wonder where the expensive device was. I’ve done it twice! To the credit of the East Coast Aero Club pilot community, when I called the club about a week later and asked them to check if the Sentry was where I had left it, it was. In any case, I added a “Retrieve Sentry” item to the end of my checklist. 

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