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the QRH checklist…We rolled to a stop in the grass…A very
poorly written QRH emergency checklist, I believe should be
modified and improved.
CALLBACK: …The checklist is for use in-flight, not on the
ground…no changes to the checklist have been made in the
2 months since the incident occurred.
ASRS Report – Accession Number 437817
Briefing message—stabilizer trim red box. This message has
appeared on MD80 flight plans for at least 5 months, if not 6
months. This is supposedly a critical emergency procedure
that is to be committed to memory, yet there has been no
change whatsoever to the MD80 operating manual on the
subject. No revisions. No change bulletin. Nothing.
During the last 6 months, there have been several bulletins
issued, yet nothing on this critical red box change. Is the
caution text supposed to be memorized? Is the note at the
bottom supposed to be memorized? The lack of consistent
publication of this red box item is only bound to cause
problems for the airline and crews if there is an actual problem.
ASRS Report – Accession Number 478230
C21A (Learjet 35A) Fuel Imbalance – Alexander City, Alabama - April 17, 1995
• During the flight and unknown to the crew, the right standby fuel
pump continued to operate uncommanded after engine start because
of two bonded contacts on the fuel-control panel
• Control was lost of the aircraft while maneuvering for an emergency
landing – all eight individuals on board perished
• This prevented fuel from being transferred to the right wing during
normal transfer procedures - caused a severe fuel imbalance
The flight manual did not contain a checklist for correcting a
fuel imbalance that occurs during the transfer of fuel
C21A (Learjet 35A) Fuel Imbalance – Alexander City, Alabama - April 17, 1995
Such a checklist was available from the manufacturer but the
operator did not contract for flight manual updates from the
manufacturer
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Broad, Over-arching Issues
15 Different Categories of Issues:
Selected Emergency Equipment and Evacuation Issues
Issues Related to the Aircraft
Issues Related to Training
Issues Related to Humans
Issues Related to Checklists and Procedures
Emergency and Abnormal Situations Project
Taxonomy of the Domain
Checklist
Use
Human
Performance
Personnel
Issues
Crew
Coordination
& Response
Roles and
Behavior of
Others
Issues Related to Humans
Distribution and prioritization of workload and tasks, distractions, etc.
Errors made when completing checklists, non-compliance, not accessing
checklists at all, etc.
Effects of stress, time pressure, and workload on cognitive performance, memory,
creative problem solving, etc.
Emotional / affective responses to stress
Influence of crew backgrounds, experience levels, company mergers, etc.
Role of cabin crew, ATC, dispatch, maintenance, ARFF, MedLink, etc. and the
degree to which their procedures are consistent / complementary
B727 Rapid Decompression – Indianapolis, Indiana – May 12, 1996
• The CA, FE, and lead flight attendant each lost consciousness for a
brief time during the event
• In actuality, it appears the FE opened the outflow valve and the
aircraft rapidly lost pressurization
• As per the CA’s instructions, FE said he turned the right pack on
and then “went to manual AC and closed the outflow valve”
• CA helped FE to find the button to turn it off and noticed that
the second pack was off
• Right before reaching cruise altitude at FL330 (10058.4 meters),
cabin altitude warning sounded
B727 Rapid Decompression – Indianapolis, Indiana – May 12, 1996
The FE did not use a checklist for re-instating the second pack
B727 Rapid Decompression – Indianapolis, Indiana – May 12, 1996
The FE did not use a checklist for re-instating the second pack
The CA did not call for and the crew did not complete any
emergency checklists including the decompression checklist and
emergency descent checklist
The CA did not put his oxygen mask on immediately when the
altitude warning sounded as required by procedures
DC-10 In-flight Fire – Newburgh, New York – September 5, 1996
• During cruise at 33,000 ft (10058.4 meters) cabin/cargo smoke
warning light illuminated – the FO was the PF
• The FE, without input from the CA, completed the checklist branch
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