FLYER XJT Safety Committee December January 2005 2004 ExpressJet MEC Checklist is Complete, I Think As most of you know, the Safety Committee continuously monitors FOQA and ASAP data in conjunction with the company Safety and Flight Standards and Training departments. Recently, analysis of this data has revealed a common theme in some trends that, at first, appear to be unrelated. The trends in question are flap over-speeds and altitude and clearance deviations. Flap Over-Speed XJT MEC Chairman Capt. Mark Leneski Vice Chairman Capt. Jeremie Brown Sec. Treasurer Capt. Mark Waterworth Flap over-speeds have been a problem for the last few years. The trend first showed up on FOQA data. Early on most of the over-speeds involved Flaps 45. This problem was virtually eradicated by the reduction in target speeds and the provision for temporary exceedance of the Flaps 45 speeds on the ER/LR fleet. Since those changes, some over-speeds occurred during arrival when the flaps were selected down at too high a speed but the majority of events occurred when the flaps were left at Flaps 9 past V fs on departure. When the checklists were extensively rewritten in 2002 we paid a great deal of attention to this problem and sought very hard to find a checklist change that could reduce the incidence of flap over-speeds. At that time, we were unable to find a change that would reliably reduce the problem and we determined that the best way to solve the flap over-speed issue was to modify the aircraft to include a warning when the aircraft speed exceeded the authorized speed for the present configuration. When the company went to Embraer to request such a modification, the costs turned out to be prohibitive. So at that time we chose not to make changes to the checklist and to rely on education and the professionalism of the pilot group to solve the problem. In other words, the only solution available to us was to point out the problem and rely on strict checklist discipline to reduce the incidence of flap over-speeds. And, for a while, this seems to have worked. From late 02 to late 03 we saw a steadily decreasing trend in the number of over-speeds in the FOQA data. The Flyer is published by the ExpressJet Master Executive Council 3808A World Houston Parkway, Houston, TX 77032-2475 Phone: 281.987.3636 Fax: 281.987.2003 Internet: http://www.calalpa.org 2004, ALPA ExpressJet Master Executive
In recent months, however, that trend has reversed and begun to climb. In the last two months maintenance has become aware of the problem because the over-speeds being reported have been so severe that extensive maintenance inspections (sometimes over 4 hours) have been required. These inspections have led to aircraft downtime and to delayed or cancelled flights. The graph below shows the exceedance rates for each month for the past two years. You can see that the rates started down in late 02 and remained down or mostly flat until late 03 with a sharp rise in late 04. The majority of the rise can be attributed to the increase in Flap 9 exceedances. Most of these appear to be occurring during departure....we determined that the best way to solve the flap over-speed issue was to modify the aircraft to include a warning when the aircraft speed exceeded the authorized speed for the present configuration. To give you some example of the kinds of problems we are seeing in the ASAP reports, the following paragraphs are quotes from reports received over the last six months. I performed the after T/O flow and raised the flaps to 0. I was then distracted by ATC with a new frequency change which was an error. I forgot to complete the after takeoff checklist to verify the flow was complete. At cruise, 31,000 ft, the captain noticed that the A/C was not accelerating. He noticed the flap handle was in the 0 position but did not lock into place; therefore the flaps were still at 9 degrees. The flaps were raised and the flight continued without further incident. The speed never exceeded 250 kias, but the altitude limitation was exceeded for the flaps. MX was notified at IAH. While climbing out from CLE to DFW I (Capt.) was Flying and called for flaps zero, climb thrust, and After T/O Checklist. Climbing through about 18000 and at about 290 KIAS, I 2
realized our flaps were still at 9 degrees. We slowed to about 245 KIAS and retracted the flaps. Shortly thereafter, I called dispatch and requested to speak to MX about the situation. They advised us to continue to DFW and they would have a different AC for us to swap into. As it turns out, they brought us an AC from IAH with a couple of mechanics. We took the good AC and left to CLE on time and arrived early into CLE. After climb out, the flap selector was moved but not placed in the detent. Thus the flaps remained at 9 degrees. This was subsequently missed on the after takeoff checklist and we climbed to FL290. At ATC request, we expedited the climb. Therefore, the climb was performed at relatively slower speeds and the speed limitation of 250 knots was only exceeded for a few minutes at FL290. At that point, in the level off, we were able to ascertain that the aircraft was handling different. We recognized the flaps being at 9 degrees and finished placing the flap selector into the detent. Climbing out of Cleveland, after a diversion for MX, I failed to retract the flaps on schedule. We got vectors for our climb during our acceleration height call outs and were distracted from our normal Flows. We were given several requests for altitude and heading changes and to increase our climb rate up thru 23000ft. I never pulled out the after T.O Checklist. It wasn t until we leveled at 35000 and weren t accelerating right that we notice the flaps still selected to 9 degrees. We don t think we ever got faster than 270 KIAS because of our climb restrictions by ATC. This could have made it harder to detect because we were watching vertical speed and not trying to accelerate. We were well above the 20000 ft altitude limit for flaps extended. I am completely perplexed at how this happened. I have had several long hours to think about how this could have happened. I pull out the checklist and read it verbatim every time. I read all the FOQA data reports and am very aware of this common problem. I do not know why this time I didn t pull out the checklist and why my flows were so disrupted that I didn t retract the flaps. There were several contributing factors that could have played a part. The show times for all three previous duty days were in the afternoon and the last day we had a 3:30 am wake up call after a short night. We were running behind schedule due to our MX divert to Cleveland. ATC gave us numerous radio calls during the initial climb segment but that is not out of the ordinary. I hope in the future added vigilance on both our parts will prevent a reoccurrence. I also think an oral warning based on flap speed limits plus 5 KIAS would really help all of us that have made this stupid embarrassing and potentially dangerous mistake. 3
Until this modification can be incorporated, however, the only defense against this problem will remain pilot vigilance and professionalism. While climbing out of EWR, I noticed that the flaps were never retracted from 9 degrees. Unfortunately, we had already exceeded the flap 9 speed limitation of 250 KIAS. We were at 290-300 KIAS when we realized the flap situation. I immediately retracted the flaps to 0 degrees. I then used SELCAL to contact maintenance control and dispatch to let them know the situation. We decided it was better to land in CLE and switch aircraft so that we would not have to leave passengers behind in MSP. We landed safely in CLE and continued on to MSP after switching aircraft. I fully understand the problem that arose in this situation, and realize that even though the FO might do the after takeoff checklist, we should always double check each other. I know mistakes are made, but I have always looked at the flap settings after takeoff and on landing. Although I did not on this occasion, I assure you that I always will in the future. This is a two person cockpit, and we are there for each other. I feel this problem began just after takeoff, doing the Newark 7 departure. The radios were very busy, and we were turning to a new heading, and getting a new altitude, when I called for flaps up, after takeoff checklist. I have discussed the problem with my FO, and we both know that we will pay more attention to doing and not just reading the checklists. We apologize for the inconvenience and problems we may have caused, but we have surely learned our lesson. In order to find a solution to the flap over speeds, ALPA Safety, Company Safety, Flight Standards and Training, the Human Factors Team and Flight Operations met and considered several options. The first thing to come out of this is a change to the checklist which we will see soon. This change will modify the After Takeoff checklist to require both the Captain and FO to verbally verify the flaps are at 0 with the rest of the checklist continuing to be conducted silently by the PM. Some of the company and ALPA personnel believe this checklist change will reduce the overspeed events. All of us recognize, however, that the real solution is to modify the aircraft to provide a warning when the speed exceeds the limits of the current aircraft configuration. The company has readdressed the issue of modifying the aircraft with Embraer. (We are currently waiting for their reply to our request.) Hopefully we can convince Embraer to add an EICAS message when the flap speeds are exceeded; this should be much less expensive than the originally proposed modification. Until this modification can be incorporated, however, the only defense against this problem will remain pilot vigilance and professionalism. We must discipline ourselves to slow down and carefully insure each checklist item is properly completed each and every time we run the checklist. 4
Clearance Deviations Another trend that is going in the wrong direction is the number of deviations from an ATC clearance that are being experienced during our flights. As you can see from the chart below, the number of deviations reported has nearly doubled over the course of this past year. While there are a number of causes for these deviations, one of them stands out as by far the most frequent cause. That is that either the route loaded in the FMS was not verified against the clearance actually received from ATC, or an enroute change was entered without both crewmembers verifying that the change complied with the new clearance. The chart below was prepared by the Safety Committee this past summer. We reviewed every clearance deviation for the prior six months and assigned a probable cause to each one and then compiled the various causes for analysis. The chart shows the frequency of each cause as a percentage of the total Navigation Errors analyzed. During the major checklist rewrite in 02, one of the goals was to reduce clearance deviations. Two major changes were instituted to accomplish this goal. First, we added a checklist requirement for both crewmembers to verify the cleared flight plan was properly loaded into the FMS prior to the flight. This item was added to the Before Start/ Pushback checklist. This location was chosen because the final clearance was not always available when the Receiving Checklist was not always available when the Receiving Checklist was accomplished. The second change was kind of buried in Section 4 but it required that any changes to the route be entered by one pilot and verified by the other. The CFM now has some very specific guidance on this subject in 5
the Automation Guidelines portion of Section 3 (see page 3-236 in particular). The following paragraphs provide examples from ASAP reports received over the past six months: We departed from Cleveland enroute to STL. We were late approximately two hours in our departure to STL. When we arrived inbound from Syracuse we were immediately pressed by the gate agent and ops to turn as fast as possible due to many World Series baseball fans on board our delayed flight to STL. I went to ops to look at the radar and my FO stayed with the aircraft and prepared for the next flight. When I arrived back into the cockpit he had the flight plan already plugged into the FMS. I asked if the FMS had the correct flight plan in it and he indicated that it was OK. We departed to STL. As we neared ROD VOR, ATC asked if we were on a heading. The controller indicated that we were 12 miles off course. At that time I noticed that we never had ROD in the VOR and that we were going to VHP. We put ROD into the FMS and started towards it. ATC then gave us direct VHP. Looking back at the situation I should have spent an extra couple of moments rechecking the flight plan in the FMS. I should also not have allowed the gate agent and ops to rush us to turn the aircraft. 6 The flight departed late due to paperwork issues. The dispatch release was not available until after go time (despite calls to ops, release desk and dispatch), and therefore fueling was delayed. The release was then amended verbally by phone
since there was no mention of terrain clearance or driftdown. After passing NLD enroute to GDL, MTY Center questioned our flight plan and advised that we were not on UJ11. It became apparent that during the rush at the gate to enter all the late arriving flight plan information, and make the necessary amendments to the release, the wrong airway was entered in the FMS. We entered UJ11.CDR, instead of UJ11W.CDR. Both routes take you to CDR, so the error was not obvious; one was just missing the W. Center cleared us to CDR and the flight proceeded normally. We had been given direct to YQG out of FL270 on descent to FL240. However, direct to YXU was selected instead. Cleveland center advised us that we were off course, and told us to fly heading of 140 for direct to YQG. Upon review of the GONNE arrival in the FMS we found that YQG was not part of the arrival. Instead the transition was YXU. We loaded in YQG and selected direct. No further problems were encountered. This situation could have been avoided by placing more emphasis on situational awareness, and by confirming the fix that had been selected in the FMS. I was given a clearance to fly direct VUZ however I flew direct to VXV. I found out my error when ATC queried me. I told him I made the mistake and corrected approx. 4 degrees to the left in order to go direct to VUZ. The error was made because I failed to double check the correct identifier in the FMS. In the future I will be more careful before I hit direct. Altitude Deviations Another problem that has been with us for some time but has taken a recent turn for the worse is altitude deviations. This has been one of our top concerns for the last two years. We instituted the Point and Shoot procedure for altitude alerter changes and compliance with this procedure has been reducing the occurrence of altitude deviations. However, in the last few months we have seen an increase in altitude deviations caused by the crew s failure to reset altimeters passing through the transition altitude or level. Here are some examples of these reports: We had been cruising at FL 18000; Capt was on interphone to Flt attendant, cleared to 14000. FO acknowledged, and descended. Leveled at 14000, BOS asked us to confirm 14000, and gave 30.24 for altimeter setting. We realized we hadn t done the in range check or reset altimeter still at 29.92. We reset altimeters and did in range check. In the last few months we have seen an increase in altitude deviations caused by the crew s failure to reset altimeters passing through the transition altitude or level. 7
Center gave us a late clearance to cross WAKEM at 10000ft. We were at FL 190. We leveled off at 10000 ft. at WAKEM intersection and realized that both of us had 29.92 still set in our altimeters. The local altimeter was 29.47 resulting in us being about 500 feet low! This could have been a disaster but luckily no other aircraft appeared on TCAS and approach said nothing. We immediately climbed back up. As always there were several factors involved in our mistake but the biggest one was the fact that we were distracted with our cockpit tasks. We should have been concentrating on getting the in range done at the appropriate time. Instead, we were talking about how the controller gave us a late clearance. We also both were tired and looking forward to going home. These extraneous items were unimportant. Each of these events would have been prevented by careful accomplishment of the In Range checklist at an appropriate time. Checklist Discipline Line Check Airmen are reporting that some of us have become a little lackadaisical in the way we perform checklists. 8 So what is the common thread between these problems? Since these are problems we as pilots know could happen we are usually attentive to the opportunities to insure they don t. We usually pay strict attention and insure we set up the FMS correctly the first time and verify any changes we make. We usually pay strict attention to configuration changes on the aircraft and make sure they occur at the proper time. Each of these problems is addressed in our manuals and procedures. Each of them has a checklist item dedicated to insuring the flow was completed correctly. Virtually every flight is completed without either of these problems occurring. However, on too many flights, one or the other does occur. So why do these problems continue? Anecdotal information from the line check airmen may prove to be the key to understanding the root cause of these problems. Line Check Airmen are reporting that some of us have become a little lackadaisical in the way we perform checklists. They have seen crews accomplishing checklists from memory, rushing through checklists without actually verifying the items, and accomplishing checklists at inappropriate times. Although it is almost impossible not to memorize the checklists, it is important that we not accomplish the checklist from memory. There are essentially three different types of checklists. There are written checklists, flows, and mnemonics (the old GUMPS check). A basic premise of checklist design is that you should always have two checklists for each critical step. Here at ExpressJet we rely on flows backed up by the Normal Checklists for normal operation. (See CFM 3-3 for our checklist philosophy.) So in order for our checklists to provide the redundancy required, they have to be accomplished verbatim from the written document.
The Check Airmen have reported observing some pilots rushing through checklists during especially busy departures or arrivals. When it gets busy and when we are fatigued are the times when it is most important to have the checklists to back us up. If you are a little fatigued, it is easy to see what you expect to see or to just recite the checklist without actually checking anything. At these times it is even more important for us to slow down and carefully verify each item on the checklist. The only way we can do this is if we make it a conscious habit to stop and verify each item every time. Then, in the heat of battle, your practiced habit will be to carefully look at each item and actually verify that it is in the correct position. Finally, the Check Airmen have reported some of us accomplishing the checklists at inappropriate times. While the After Takeoff flow needs to be accomplished at a specific time, there is really no rush to get the checklist done. Especially when flying the Newark 7 the OVEMA One Bravo or some other departure that places a higher than normal workload, flying the airplane, navigating the departure and communicating with ATC can all be accomplished before the checklist. When time and workload permits, then accomplish the checklist assuring that each item is correct before announcing that The Checklist is Complete. What do I do With All This Information? So we have three major safety issues that appear to be related to the way we accomplish our checklists. Does that mean that we have a major problem with checklist discipline? Well let s look at the data. We appear to be having about 130 clearance deviations per month. Currently we are flying about 36000 flights each month so we are seeing deviations on about 0.36% of those flights. Most of us can operate for years without seeing one of these deviations; however, the potential consequences of a clearance deviation or an extensive flap overspeed are so large that we do need to do whatever we can to reduce the incidence of these problems even further. We do have a checklist change in work for the flap over-speeds and the company is working with Embraer to change the aircraft to notify us when we are exceeding the speed for the current configuration. However, the rest of the buck will continue to stop in the cockpit. The only way to continue to reduce the occurrence of these events is for each of us to commit ourselves to carefully and thoroughly accomplishing each checklist each and every time. The more fatigued I become and the more rushed I am, the more I have to slow down and concentrate on the checklist accomplishment. That way, even when I am tired and busy, the checklist is complete really does mean that all of the items are in the proper configuration. The only way to continue to reduce the occurrence of these events is for each of us to commit ourselves to carefully and thoroughly accomplishing each checklist each and every time. 9
ExpressJet Master Executive Council 3808A World Houston Parkway Houston, TX 77032 (281) 987-3636 10