4-3 for flight deck conditions. However, this should be tested under all potential operational conditions.
4.5.2 Line Spacing. Place sufficient space between lines of text. Using 25 to 33 percent of the font size between lines (e.g., 3 to 5 points space between lines using 14 point font) will make the text easier to read than if there was less space between the lines.
4.5.3 Font. Unusual or ornate fonts should be avoided.
4.5.4 Case. Use standard capitalization rules. Text in all capital letters is harder to read than text in lowercase. Use all capitals very sparingly and only for meaningful emphasis, or to represent labels that are commonly encountered in capitals (e.g., VNAV).
4.5.5 Grouping. Use visual techniques (e.g., white space created by extra lines, indentation) to delineate grouping of steps, lists, and the components of logic statements.
4.5.6 Justification. Paragraphs of text should be left aligned. Do not use right and left justified to produce aligned right and left edges, because it adds spaces between letters and/or words that make the paragraph harder to read.
4.5.7 Line Length. Traditionally, checklists have been formatted to resemble an index or table of contents with corresponding components (e.g., Challenge…Response) left and right justified and joined with dots or lines. This format is acceptable; however, excessively large gaps between the components should be avoided. The wider the gap, the greater the chance the pilot will inadvertently skip to the next line due to perceptual misalignment.
4.6 Place Keeping.
4.6.1 Title. Clearly identify the procedure by title (e.g., “Before Start”) and the objective of the procedure when it is not obvious from the title.
4.6.2 New Lines. Begin each step in a procedure, each element in a logic statement, and each item in a multiple item list on a separate line.
4.6.3 Bullets and Numbering. Use numbers, bullets, and lines, as appropriate, to indicate the beginning of each step. Using numbered lines can reduce navigation and place-keeping errors in the event that an interruption occurs. Numbered steps also facilitate navigation between procedures when it is necessary to “GO TO” a step within a procedure.
4.6.4 Continuation. Clearly specify if a procedure continues onto another page
(e.g., “Continues on Next Page”).
4.6.5 End. Clearly mark the end of a procedure with a standard symbol or wording
(e.g., “Checklist Complete”).
4.7 Emphasis. Emphasize cautions and warnings (e.g., CAUTION, WARNING), conditional words (e.g., IF, THEN), and important notes (e.g., NOTE). Timed events or steps that must be monitored for a period of time should be emphasized. Irreversible items should
4-4 be emphasized before the action is specified or taken. Techniques for calling attention to certain words or phrases should be used sparingly but consistently. Overuse of emphasis reduces its effectiveness and makes the procedure hard to read. Techniques for emphasis include:
4.7.1 Typographical. Typographical emphasis techniques include bolding, italicizing, underlining, and capitalization.
4.7.2 Graphical. Graphical emphasis techniques include framing, shading, coloring, and the use of standard symbols.
4.7.3 Spatial. Spatial techniques for conveying emphasis include using white space to group text and reserving places on the page or screen for selected types of messages.
4.7.4 Verbal. Verbal emphasis may be conveyed by using reserved words (e.g., Important, Note, Caution, and Warning).
4.8 Conditional Steps. In many procedures, some steps should be executed only when specified conditions occur. These conditional statements are a frequent source of confusion, particularly for novices, or with rarely used procedures. This problem can be alleviated by keeping the statements well structured, clearly phrased, and as short as possible.
Conditional statements should present all of the conditions clearly so that the correct choice is easy to identify. The steps that are associated with each condition should be grouped clearly. The end of this block of steps should be clearly identified and the action or procedure to be performed after completion of the block should be clearly specified. If there are embedded choices, then these subsidiary conditions also should be clearly delineated and the associated steps grouped in an unambiguous fashion.
Conditions should always precede actions. Actions that are irreversible should be identified in the condition preceding the action. Conditional statements may begin with one of the following words:
1. IF – use to indicate a condition that may or may not happen.
2. WHEN – use to indicate a condition that must be met before an action is taken and that condition is very likely to occur (e.g., “WHEN pressure reaches 120 psi THEN put gear down.”).
3. THEN – use to identify actions that should be taken when the specified condition occurs.
4. AND – use to combine two conditions that must be met before the action is taken.
5. OR – use to indicate that one or more of several conditions must be met before the action is taken.
4-5 If alternative formats are used, ensure they are used consistently and the intention is clear.
For example:
IF light x is lit THEN open valve y IF light x is NOT lit THEN open valve z Which also may be expressed as:
CHOOSE one:
Light x is illuminated ● Open valve y Light x is extinguished ● Open valve z
4.8.1 Complex Conditional Statements. Avoid using combinations of AND and OR whenever possible. In general, use separate steps instead.
4.8.2 Waiting, Continuous Actions, Repeated Actions. In some cases, an action must be continued or repeated until some condition occurs. In these cases, specify (1) what actions are to be repeated, (2) the conditions under which those actions should be stopped, and (3) whether the remaining steps in the procedure can be continued in the meantime. For example: “Hold button depressed UNTIL pressure reaches 120 psi, THEN GO TO step 5 in this procedure.”
4.9 Cross-References. Cross-references to other procedures should be avoided whenever possible. In most cases, a “Go-in, Stay-in” strategy should be used whereby all necessary steps for completing a procedure are included in that procedure. In some cases, this may prove impractical.
4.9.1 Explicit Reference. When used, cross-references should be explicit and use consistent wording.
4.9.2 Version Control. When references to other procedures are required, a system should be in place to monitor version control. Changes made to either the referring or referred procedures could affect the execution of the included steps.
4.10 Warnings and Cautions. Warnings and cautions in procedures should be used sparingly.
Overuse of warnings will decrease their effectiveness. Often “warning” is used to convey a more urgent or critical matter than “caution.” AC 25.1322-1, Flightcrew Alerting, contains definitions for these terms.
4.10.1 Components of Warnings and Cautions. Each warning or caution should identify a single hazard, the consequences of the hazard, and any critical time constraints. Actions should not appear in warnings or cautions.
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4.10.2 Placement. Warnings and cautions should be placed on the same page, and prior to, the steps to which they apply. Procedural steps should be graphically separated from warnings and cautions.
5-1 CHAPTER 5. DEVELOPING CHECKLISTS
5.1 General. Checklists are a special type of procedure. They are often the form into which extended procedures are distilled, and often the most common and most frequent form through which people interact with formal procedures. On the flight deck, checklists are an important tool in making sure that operational tasks are performed in a standardized fashion.
Checklists are of no value if the flightcrew is not committed to their use. Without discipline and dedication to using the checklist at the appropriate times, errors will inevitably occur.
Although it may be published in a manual, a checklist is designed for independent use so that the user will seldom need to reference that manual, especially after having been previously trained on the content therein. Checklists are used to ensure that a particular series of specified actions are accomplished in the correct sequence and to verify that the correct aircraft configuration has been established in specified phases of flight.
Checklists have been a significant part of the foundation of pilot standardization and flight deck safety for years. Such procedures, when applied in a disciplined and standardized fashion, are intended to support human performance regardless of circumstance. The checklist is an aid to the memory and helps to ensure that critical items necessary for the safe operation of aircraft are not overlooked or forgotten.
Checklists must be easy to access, easy to read, and easy to use. Checklists should provide enough information to enable the flightcrew to verify it is the correct checklist before they begin using it. Instructions should be concise, but sufficient information must be provided so that actions are performed correctly and essential issues are considered.
The checklist must accommodate the demands of high-workload phases of flight and the performance limitations experienced by humans when under stress. It should respond to the specifics of the situation but also assist crews in their management of the overall task.
5.1.1 Consistency. Operators should standardize checklist items and the sequence of those items to the maximum extent practicable, given possible make, model, and series (M/M/S) and variant differences across the fleet.
5.1.2 Type of List and Manner of Execution. For most normal procedures on the flight deck, a “flow” is conducted as a sequence of actions done from memory to configure the aircraft and its systems. The flow is followed by a checklist containing a subset of items from the flow that may be the most critical items within that flow and items that confirm the flow was done correctly.
5.1.3 Timing. Given the criticality of the checklist procedure, the crew’s ability to pay full attention to its execution is crucial. The timing of the checklist must be such that it would minimize the distractions and concurrent tasks. Timing of checklists should be designed not to interfere with other tasks and be resistant to interruption. For example, a “Taxi Checklist” that is to be accomplished during taxi might appear as an efficient use of crew
5-2 time, but it creates a high-risk situation because the crew cannot pay full attention to both the taxi and the checklist.
5.1.4 Roles. The role of providing the right cue at the right time for initiating the checklist is always assigned to one of the two pilots; usually, the pilot in command (PIC) on the ground and the PF in the air. Typically, the cue comes in the form of a verbal call (e.g., “before start checklist”), and serves to prompt the other pilot to retrieve the checklist.
Assuming a checklist for normal operation involves both crewmembers in a challenge-response method, both pilots would then be expected to direct their attention to the checklist task. The pilot responsible for leading the checklist begins by calling out (or “challenging”) the first item on the list. The other pilot verifies that the item has been done correctly and provides the relevant response. There are several variations on the theme of the challenge-response method: Following the response of the responding pilot, the challenging pilot may go on to challenge the next item, may also verify the state of the item, and may or may not provide a verbal response. The verification may or may not involve specific gestures such as pointing to the relevant switch, lever, or indication.
5.1.5 Initiation Anchor. The initiation of a checklist is best anchored in a clear cue that cannot be easily removed, obstructed, or forgotten, such as the occurrence of a particular event
(e.g., arrival at a point 2,000 feet prior to the hold-short line cues the initiation of the Before Takeoff checklist). Often, initiation of a checklist is left open, only constrained by a time window (e.g., Taxi checklist to be completed anytime during taxi) and acceptable circumstances (e.g., when both pilots are free of other duties). Cues for initiating checklists in these situations are often more of a personal technique among pilots, who use internal as well as external flight deck cues to aid them in remembering to initiate the checklist at the correct time. However, such “floating” checklist initiations create a high risk of failing to initiate the checklist on time and thus having to rush through it, or failing to initiate the checklist altogether. The importance of having clear and reliable external cues to trigger the initiation of the checklist procedure at the right pause point cannot be overemphasized.
5.1.6 Completion Signal. The checklist completion signal indicates that the checklist has indeed been performed in its entirety and leads into the next segment of activities. The most common completion cue is a verbal annunciation such as the “Before Taxi checklist complete” by the pilot who has been responsible for leading the respective checklist. The completion call should be written out as the last line item, or centered under each checklist. When the completion call is not explicitly listed on the checklist, a layer of redundancy is removed and the risk of omissions increases.
5.1.7 Checklist Verification. During the design of the checklist it is important to keep in mind that all checklist designs are subject to human error. Crewmembers may omit and skip checklist items or erroneously respond to a checklist at times believing that an item or a task was accomplished when it was not. At other times, crewmembers may see what they expect to see rather than what is actually accomplished or indicated.
One strategy that helps to overcome human error is to develop policies for using checklists which require stringent cross-checking and verification and reinforce those
5-3 policies through crew training programs. The procedures intended for checklist use should be clearly written in the operator’s operating manual and must be compatible with the operator’s CRM philosophy.
The policy should include, but not be limited to, the following items:
1. Flightcrew responsibilities for maintaining aircraft control, analyzing situations, and requesting the appropriate checklist in normal, abnormal, non-normal, and emergency situations.
2. The specified crewmember responsible for initiating each checklist.
3. The specified time when each checklist is to be initiated.
4. The specified crewmember responsible for accomplishing each item on the checklist.
5. The specified crewmember responsible for ensuring that each checklist is completed and reporting that completion to the crew.
6. Crewmember responsibilities for bringing to the attention of the PIC and the rest of the crew any observed deviation from prescribed procedures.
5.2 Methods for Managing Checklist Accomplishment.
5.2.1 Single-Pilot Aircraft. For single-pilot aircraft, operators should mount the Before-Takeoff and the Before-Landing checklists on the instrument panel. When aircraft characteristics allow, the operator should develop touch-verification procedures which include a requirement that the pilot touch each control to verify it is in the correct position.
5.2.2 Multi-Pilot Aircraft.
5.2.2.1 Flight-Related Checklists. Flight-related checklists should be accomplished by one crewmember reading the checklist and the second crewmember confirming and responding to each item, as appropriate. Exceptions to this may be the After-Takeoff and After-Landing checklists. While airborne the PF should not be distracted from controlling the aircraft flightpath to perform a checklist item that another crewmember can accomplish. Only one pilot should be in a head-down posture at any time the aircraft is in motion.
5.2.2.2 Verification. Crewmembers should be directed that when they observe that another crewmember is not taking or has not taken a required action, they are required to inform the crewmember.
5.2.2.3 Checklist Completion Tracking. The crewmember responsible for initiating the checklist should be responsible for ensuring that the checklist is completed systematically and expeditiously. This crewmember should be responsible for managing interruptions, cross-checking controls and indicators to ensure that the required actions have been accomplished, and reporting that the checklist has been completed.
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5.2.2.4 Callouts. A callout should be made by the pilot if he or she is accomplishing a task that requires him or her to be “heads down.” This helps ensure the other pilot is not heads down at the same time.
5.2.2.5 Critical Items. Critical items should be verified by both the PF and PM.
1. In the before-start phase, flight guidance and navigation items are considered critical items. Concurrence should be required from both pilots when the same setting is required for more than one device (such as computers, flight instruments, and altimeters). Inertial platform alignment and computer programming should be accomplished by one crewmember and independently confirmed by another. As many of these checklist items as possible should be accomplished and verified before the aircraft is moved.
2. In the taxi and pre-takeoff phases, aircraft configuration (such as flaps, trim, and speed brakes) and flight guidance items (such as heading, flight-director, altitude select panel settings, and airspeed cues) are also critical items.
Consideration must be given to non-standard operations such as deicing which may result in configuration changes from what was previously set.
3. On approach, flight guidance checklist items are critical. The PF and PM should be required to confirm and respond to these items when incorporated in a checklist. Concurrence should be required when the same setting is required on two separate devices (such as computers, flight instruments, or altimeters).
4. Checklist items that are critical in the before-landing phase vary with the type aircraft involved. The landing gear and flaps are critical items and should require a confirmation and response by both pilots when incorporated in a checklist.
5. A checklist should not be depended upon to initiate a change in aircraft configuration. Operators should key aircraft configuration changes to specific operational events (e.g., direct the landing gear to be extended at glide slope intercept). For any change in configuration, a command from the PF and an acknowledgment from the crewmember taking the action should be required.
5.2.3 Interruptions. Crewmembers frequently cannot complete a checklist because of interruption or an item on the checklist has not yet been accomplished. Operating procedures must be established to ensure that the correct checklist sequence is completed after an interruption. If the sequence cannot be re-established or the crew is unclear on where to resume the checklist, the appropriate section of the checklist should be reaccomplished from the beginning.
5.2.4 Representative Items. Representative items are selected items that represent a whole subset of flow actions such that if the selected item was performed, the whole subset must have also been performed. For instance, if all engine indications are in the green, the whole engine start sequence must have been done correctly; therefore, checking the engine indications can serve as a representative item for the engine start sequence.
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5.3 Item Order. The order of the items on the checklist can mirror the sequence of the flow or of the operation if the flow preceding the checklist is carefully designed to:
• Take advantage of the physical layout and location of switches, displays, and indicators in the flight deck (e.g., going from left to right, or from top to bottom);
• Account for the inherent dependencies between the systems involved;
• Support human memory; and
• Be short.
Such order aids in learning and increases ease of use. Another possible ordering consideration is item priority. The probability of interruptions and distractions increases with checklist length and the time it takes to execute it. Thus, even though checklists mainly contain critical items, these could be prioritized, and those with higher importance could be placed first on the checklist.
5.4 Phraseology. The challenge portion of a checklist item is best phrased to mirror the label used in the flight deck for the corresponding switch, lever, indicator, or system. The response portion is best phrased in terms of the actual system status, switch or lever position, or the specific parameter value. For example, the autobrake system may be set to RTO, OFF, ARM, DISARM, 1, 2, 3, etc. The challenge for this system may be “Autobrake,” and the response may be “RTO”. The PF and PM should only use the phrases listed in the SOP or checklist to help reduce any ambiguity or confusion.
The generic responses of “set” or “checked” may not be very informative and does not provide as good of an opportunity to confirm correct action as the actual indication.
5.5 Common Errors That Occur When Using Checklists. Checklist errors can occur in the following areas:
• Crew overlooked item(s) on the checklist.
• Crew failed to verify settings visually.
• Operator or aircraft manufacturer checklist contained error(s) or was incomplete.
• Failing to complete a step after an interruption.
• Failing to complete a checklist.
• Completing the wrong checklist
• Difficulty in finding a checklist.
• Becoming disoriented within the checklist.
• Difficulty in confirming that the checklist action was carried out correctly.
• Problems in understanding and interpreting the checklist.
• Difficulty in determining who should be carrying out the checklist actions (PF vs.
PM).
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5.6 Preventing Checklist Errors. All checklists are subject to interruption at any point in the flight by ATC or for other operational reasons. However, operational data indicates that flightcrews are most susceptible to interruption and distraction during the ground phases before flight (i.e., “BEFORE START,” “PUSHBACK,” “START,” “TAXI,” and “BEFORE TAKEOFF”) due to time pressure and interruptions from support personnel
(e.g., ramp crew, deice crew).
5.6.1 Training Support Personnel. Many of the distractions or interruptions occurring on the ramp area can be reduced to a minimum by the aircraft operators through training of support personnel. Operators should ensure that ground support personnel who communicate directly with flightcrews are familiar with the procedures used on the flight deck and the need to avoid interrupting the crew during a checklist flow. Persons entering the flight deck to talk to the crew, or contacting the crew via interphone, should make their presence known and unless an emergency exists, refrain from interrupting any flight deck activity or talking to the crew until the crew indicates that they have completed their task and acknowledges their presence.
5.6.2 Restarting From the Beginning. It is recommended that anytime the crew is not clear as to their progress through the checklist the PIC should, without hesitation, direct that the appropriate section of the checklist be reaccomplished from the beginning.
5.6.3 Cognitive Limitations. Cognitive limitations experienced by humans when dealing with stress, concurrent task demands, and time pressure underlie many of the errors made by crews when responding to emergencies. Including more information in checklists can reduce memory load and other cognitive demands. However, the more information included in a checklist, the longer it becomes and the more time needed to complete it.
Checklist designers should include items within checklists that remind crews of information they may not easily recall and other cues they should attend to as they respond to a particular situation.
5.6.4 Checklist Error Prevention Tips.
1. Remember to use the checklist.
2. Check every item, every time.
3. Slow down and confirm significant items.
4. Deliberately read the checklist.
5. If interrupted, restart from the beginning.
6-1 CHAPTER 6. PILOT MONITORING
6.1 General. Several studies of crew performance, incidents, and accidents have identified inadequate monitoring and cross-checking as vulnerabilities for aviation safety. Effective monitoring and cross-checking can be the last barrier or line of defense against accidents because detecting an error or unsafe situation may break the chain of events leading to an accident. Conversely, when this layer of defense is absent, errors and unsafe situations may go undetected, potentially leading to adverse safety consequences. Flightcrews must use monitoring to help them identify, prevent, and mitigate events that may impact safety margins. Therefore, it is imperative that operators establish operational policy and procedures on PM duties, including monitoring, and implement effective training for flightcrews and instructors on the task of monitoring to help the PM expeditiously identify, prevent, and mitigate events that may impact safety margins.
This section describes effective monitoring, how to define and train PM duties, and integration of monitoring into SOPs. Additionally, the section discusses special considerations for monitoring autoflight operations.
6.2 Effective Monitoring. A pilot is effectively monitoring if he or she is:
1. Following SOPs consistently;
2. Clearly communicating deviations to other crewmembers;
3. Effectively managing distractions;
4. Remaining vigilant;
5. Advising the PF if the flight guidance modes or aircraft actions do not agree with expected or desired actions and intervening if necessary;
6. Continuously comparing known pitch/power settings to current flightpath performance; and
7. Considering that the primary flight displays (PFD), navigation displays (ND), and other sources of information (for example, electronic flight bag (EFB)), might be displaying incorrect information and always on the lookout for other evidence that confirms or disconfirms the information the displays are providing.
6.3 Challenges and Barriers to Effective Monitoring. There are several potential challenges and barriers to effective monitoring:
6.3.1 Time Pressure. Time pressure can exacerbate high workload and increase errors. It can also lead to rushing and “looking without seeing.”
6.3.2 Lack of Feedback to Pilots When Monitoring Lapses Occur. Pilots are often unaware that monitoring performance has degraded.
6.3.3 Design of SOPs. SOPs may fail to explicitly address monitoring tasks.
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6.3.4 Pilots’ Inadequate Mental Model of Autoflight System Modes. Pilots may not have a complete or accurate understanding of all functions and behaviors of the autoflight system. Some aspects of automated systems for flightpath management are not well matched to human information processing characteristics.
6.3.5 Training. Training may overlook the importance of monitoring and how to do it effectively. Lack of emphasis on monitoring may occur in training and evaluation.
6.3.6 Pilot Performance. High workload, distraction, and inattention can all lead to monitoring errors.
In addition, human performance limitations should be acknowledged as potential challenges for effective monitoring. The human brain has difficulty with sustained vigilance and has quite limited ability to multitask. Pilots are vulnerable to interruptions and distractions and to cognitive limitations that affect what they notice and do not notice.
It can be difficult for humans to monitor for errors and deviations on a continuous basis when errors and deviations rarely occur. This is true for the range of workload conditions experienced by the flightcrew members. Monitoring during high-workload periods is important since these periods present situations in rapid flux and because high workload increases vulnerability to error. However, studies show that poor monitoring performance can be present during low-workload periods as well. Lapses in monitoring performance during lower-workload periods are often associated with boredom, complacency, or both.
6.4 Defining Pilot Monitoring Duties. In a two-pilot operation, one pilot is designated as PF and one pilot is designated as PM. A review of operators’ manuals indicates that the roles and associated tasks of the PF and PM are not always clearly defined. Each operator should explicitly define the roles of the PF and PM to include:
1. At any point in time during the flight, one pilot is the PF and one pilot is the PM.
2. The PF is responsible for managing, and the PM is responsible for monitoring the current and projected flightpath and energy of the aircraft at all times.
3. The PF is always engaged in flying the aircraft (even when the aircraft is under AP control) and avoids tasks or activities that distract from that engagement. If the PF needs to engage in activities that would distract from aircraft control, the PF should transfer aircraft control to the other pilot, and then assume the PM role.
4. Transfer of PF and PM roles should be done positively with verbal assignment and verbal acceptance to include a short brief of aircraft state.
5. The PM supports the PF at all times, staying abreast of aircraft state and ATC instructions and clearances.