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distraction and schedule pressure are significant predisposing
conditions — but why here and not in other flight phases?
Most flight phases of air carrier and commuter operations employ
well designed standard procedures that are linear in nature
— a given required task follows another required task. For
example, in the takeoff phase the application of power is followed
by a check of engine performance or power, which in turn may be
followed by a performance check at 80 knots, and V1, VR, V2, gear
and flap retraction respectively, depending on the particular
aircraft and operator.
In contrast, duties in the pre-flight phase may be non-linear, i.e.
there may be no logical or prescribed sequence. A pilot may
need to deal with flight planning, weather information and
changes, fuel loading, dispatch manifests and release, lastminute
maintenance or MEL items, duty time requirements, or
aircraft deicing at pretty much the same time. There may be no
standard operating procedure (SOP) for assigning sequence or
priority to these tasks, nor does one task necessarily or obviously
require that another task be previously and correctly completed
— thus it may be easier to make an undetected error.
On the other hand, tasks or duties in the taxi-out phase
should be linear, yet this was the second most common flight
phase for error occurrence. It is possible that many flight
crews have not cleanly transitioned from one flight phase to
the next, and may be trying to complete pre-flight duties
during taxi-out. Another thought is that pilot’s may experience
difficulty in the transition from the non-linearity of preflight
activities to the linear duties of the taxi-out phase.
Returning to the issue of pre-flight activities, it may be appropriate
to examine cockpit or crew coordination. In an in-flight
phase where the flight crew is seated together with unrestricted
capability for interpersonal communication, the practice
of Crew Resource Management (CRM) is facilitated by
physical proximity and access. In the pre-flight phase of
operation, interpersonal communication may be degraded by
physical separation of flight crew members, and by distraction
from numerous external sources.
Recommendations:
It is suggested that companies and flight personnel
consider providing greater structure to
pre-flight activities in order to reduce the frequency
of time-related errors. Similarly, when
distraction and schedule pressure are seen to
occur in this flight phase, a reasonable response
is to slow down and carry out tasks in as linear
a fashion as practical. Where time-related pressure
is encountered from external sources, pilots
may find it a good strategy to calmly explain
the nature, probability, and typical results of
hurry-up errors to those who “apply the pressure.”
✓ Maintain an awareness of the potential for
the Hurry-Up Syndrome in pre-flight and
taxi-out operational phases.
✓ When pressures to “hurry-up” occur, particularly
in the pre-flight operational phase,
it is a useful strategy for pilots to take the
time to prioritize their tasks.
✓ If a procedure is interrupted for any reason,
returning to the beginning of that task and
starting again will significantly reduce the
opportunity for error.
✓ Practicing positive CRM technique will
eliminate many errors — effective crew coordination
in “rushed” situations will catch
many potential problems.
✓ Strict adherence to checklist discipline is a
key element of pre-flight and taxi-out task
execution.
✓ Defer paperwork and nonessential tasks to
low workload operational phases.
The Aviation Safety Reporting System is a cooperative program established by the Federal Aviation Administration’s Office
of The Associate Administrator for Aviation Safety, and administered by the National Aeronautics and Space Administration.
Issue Number 6
❖ Ground Jet Blast Hazard (by Rowena Morrison) ...............................4
❖ Emergency 911 (by Linda Connell & Marcia Patten) .................................12
Plus Lifeguard and Priority Handling ...................................17
❖ Lost Com (by Charles Drew, Andrew Scott, & Bob Matchette) ......................19
❖ ASRS Database Statistics (by Loren Rosenthal) ..........................26
Issue Number 6 3
Here is issue six of ASRS Directline. Our previous issue of Directline featured two articles that were adaptations
of research papers that were presented at the Ohio State University (OSU) 7th International Symposium on
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