The Humble Checklist
Here is a post about process execution using four aviation related incidents as examples. No harm was caused in three of those, but in the first one below, people lost lives. In essence flying a plane, and its operations on the ground are expected to be a streamlined process. But, given the fact that much of it is human dependent, the chances of error creeping in, always remain.
Let us quickly check through the incidents to see what happened.
Incident 1
The first incident happened on Aug 7, 2020 to an Air India Express aircraft flying back passengers on a Vande Bharat flight, from Dubai. The pilot landed on a wet and slippery runway, somewhere at the halfway mark, and ignored a “go around” call from the non-flying pilot. Later, attempted a go-around and failed. The aircraft broke in multiple parts, and killed 21 people including the flying crew. A similar incident had also occurred in Mangalore a few years ago.
The opposite (in terms of process and result) of this incident took place at Heathrow on Jan 31, 2022. The British Airways A321 attempted to land in strong crosswinds, bumped twice, aborted the landing and took off again. It did a go-around, and landed safely without incident the second time around.
What exactly happened
Before we mention the difference between the cases, you would want to know that the flaps (on the trailing edge of the wings) are required to be at 5o, 15o and 45o during taxi, takeoff and landing respectively. This, naturally, has to do with the amount of lift and resistance required during the three attitudes of the aircraft.
Now, watch the British Airways landing video again. After the second bump on the port main wheel, you will see the plane starting to take off again. At that time, along with the second bump, do notice the flaps on the starboard wing (closer to you) getting retracted rapidly. That is the retraction from 45o to 15o, from landing to takeoff.
The procedure in these situations calls for one of the two pilots to make the call to abort landing. The flying pilot is to immediately start a go-around procedure. Simultaneously, the non-flying pilot engages with the take off checklist and starts reading it out and executing it. One item in this checklist is retraction of the flaps to take-off position (15o).
All of that worked well, evidently, at Heathrow. But, not at Kozhikode. The post incident investigations published a damning report. The pilots did not follow basic procedure. They tried to land twice earlier, and went around. During the third attempt, the non-flying pilot called for a go-around again, but the flying pilot ignored it and eventually landed beyond the half way mark. Then, after realizing the overshoot, he decided to do a go-around. At that time, he increased engine power. Clearly, the checklist was not used by the non-flying pilot and both of them missed the flap retraction. Naturally, the plane did not leave ground, and kept charging ahead with full thrust. As a result, in spite of brakes being applied, the aircraft went through the restrainers, the perimeter wall, and went down the incline on the further end. This left 21 people dead.
That tells you, there are three actions which caused the fatalities. First was not diverting to another airport. Second was ignoring the go-around call. The third, and the disastrous one was not using the checklist.
Incidents 2, 3 and 4
Then there are these interesting incidents. First two concern Indigo.
In one of these cases, a baggage loader happened to catch a nap inside the belly of an Indigo aircraft. When he woke up, he found himself in Abu Dhabi. He was lucky because the cargo holds of all modern pressurized aircraft are pressurized and airconditioned. So, clearly no one does a final check of the cargo hold before the doors are shut.
The second one is even more amusing. A passenger boarded the bus from the terminal to the airport, to catch his flight to Bangalore. He, also, happened to doze off soon. He was found sleeping in the same bus, many hours later, in the bus parking zone. Clearly, no one does a passenger manifest vs boarding card (electronic or otherwise) check. Imagine the security risk. What if the passenger’s checked in bag had something not very nice? This was Indigo again.
The third, must have been rather disconcerting to the passengers. 69 passengers on a Buddha Air flight, found themselves in Pokhara, though they were supposed to go to Janakpur (both in Nepal), from Kathmandu. Both cities are about equidistant from Kathmandu, but in opposite directions. The traffic folk did a quick schedule change, operations reassigned the aircraft, but no one bothered to let the pilots or the ATC know. So the pilots flew as per their earlier flight plan.
The above were examples from aviation. You have, of course, heard of surgeons leaving implements in the patient’s stomach. The root cause is exactly the same. An undeployed checklist. The same holds for even other non-critical, or non-life-threatening situations. Even at work, while a process is being followed.
Experience says that trying to execute a checklist from memory is as good as not using a checklist. That list is there for a reason; to enable humans to not depend on memory or emotion, both of which are unreliable. The bottom-line is that a process, a QA, or a checklist is meant to drive a certain type of behaviour. But if one doesn’t have the discipline to even use a checklist, there is much to be said about culture in an organization.
(This post is also syndicated to Luminatiq)
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