Poor flight discipline and use of checklists in different WW2 AFs (20% accidents!)

[Njaco]

Luftwaffe might have been abit different if General Wever had a checklist......

 

[swampyankee]

Sorry Tyrodtom, I asn't too clear.

Ron had completed a flight around the pattern in which his cockpit lights had failed and he had to follow another F-8 around the pattern to land. But he hadn't completed his night trap set and the controller told him he either had to continue or schedule another night ... and he was just about to deploy.

So ... his crew chief got the lights on and as he was taxiing out, they failed again in the middle of the checklist and the tower cleared him for takeoff. After being interrupted, he resumed his checklist mentally at the same point but actually he had skipped the "lower wings" step.

You can Google "F-8 Crusader flies with wings folded" and find the tale.

This may be just me (civilian, non-pilot, aero engineer), but I would expect "insure wings are unfolded and locked in place" would be before "taxi to runway"

 

[Reegor]

Great topic - my only concern is that I do not see very many primary sources (specifically interviews) listed as references - did I just miss that? I agree that training was an issue. Having done research at Maxwell AFB mainly looking at training accident records for B-17 and B-24 aircraft there were a number of mishaps that were due to training errors. One in particular that I recall was when a co-pilot feathered both right engines on take off in a B-24! he thought he had a hold of the landing gear control lever - the results were disastrous to the aircraft and crew. Not only that, the ensuing crash destroyed the east-west rails coming through Wendover and a freight train followed the crash by only minutes. One railcar contained brand new wrist watches and it's contents somehow vanished in the following day or so but everyone on base had no excuse for being late to anything!

Tell us more about your Maxwell research? I have not visited any of the military archives, but I would love to know more about your results. I did find yearly data on accidents "in the continental US," by aircraft type, which I am adding to the next version of the paper. I presume that "in the US" means primarily training accidents.

As far as interviews, there are tons of "stories" about accidents of all kinds, such as the great F-8 one directly above. Overall accident rates over time have validity, whereas stories about people not using checklists don't give quantitative information. So a basic fault with much of my analysis is that I can prove that checklists did or did not exist, but I cannot prove how much they were used! Do you have ideas about how to get better evidence? I'm not sure how interviews would help with this.

To follow that up, and I am sure there are others here with greater knowledge, the US Navy greatly changed its Carrier emergency OPS after the USS Enterprise and USS Oriskany accidents. One report pointed out that some of the firefighting crews in the accidents were shirtless and many serious burns were caused by this action.

From first hand accounts within the civilian jet warbird community - there are a number of "wheels up" landings that could have easily been avoided IF the checklist would have been used - thankfully no fatalities other than the bruised ego!

I've never heard of such civilian warbird incidents. Where should I look? In other chapters my focus is on commercial aviation, where there are numerous accident reports about checklist flaws and non-use. But ideally I want to trace how the "checklist culture" caught on in various places: slower in some than others. If ex-military fliers are caught landing with gear down that certainly suggests they were casual about checklists when they were in the military as well.

Procedures and quantitative flying are two more pieces. The backs of USN and USAF manuals had extensive performance tables, but how much did they actually get used? Gen. LeMay forced their use in B-29s, but I get the loose impression that nobody else was very systematic. However I've found much less discussion of this than about checklists.

 

[Reegor]

This may be just me (civilian, non-pilot, aero engineer), but I would expect "insure wings are unfolded and locked in place" would be before "taxi to runway"

I will go back and look at my checklist files. But descriptions of carrier operations are clear that unfolding wings is done twice: once to check they are working, then they are raised while the aircraft is moved into the catapult, then unfolded again just before shooting. Of course on a carrier, the shooter won't launch you with your wings up! But on a runway you don't have that external check.

Someone with direct experience want to chime in?

 

[Reegor]

Luftwaffe might have been abit different if General Wever had a checklist......

For sure. And the same problem kept happening - I mention another Luftwaffe example.

Why the heck didn't the Luftwaffe learn from these accidents?? To us today, the use of checklists looks "obvious." Both the US Air Force and Navy started including them in 1937. (So far I have found 4 manuals written in 1937 that include them: 3 Navy, plus the B-17.) But clearly it wasn't obvious, at least not outside the US.

It appears that the concept was "in the air" in the US, but not elsewhere. Lindbergh is one possible explanation, but although I have tried hard, I can't find evidence that he had checklists for things like takeoffs. (He used lots and lots of lists for managing new activities - including his own funeral!) Another possible reason is industrial engineering in manufacturing, which did a lot with procedures in the 1920s and 30s.

 

[Wendovertom]

Quick reply - I think perhaps it is my interest to get a little beyond the pure statistics. In reviewing crash reports you might find that some accidents were the fault of missing something obvious (folded wings) and something that just plain failed (nose gear in the B-24 comes to mind). Do the statistics differentiate between "pilot/crew error" and "mechanical" for the accidents?

One incident in Wendover that comes to mind was a navigator in a B-24 who stepped on the nose gear door and fell through whereupon the plane taxiied over his leg and broke it. I would assume this is a "checklist" failure but in looking at the actual report (IIRC) it says nothing about failure to follow proper takeoff protocol. Actual interviews might be revealing on how prevailing attitudes toward the checklist were - did they care or see the value? To me it would reveal the human side to the statistics and even when the statistics say, "this was available" you might find in interviews that the truth is far from it.

A link to the Air Force Historical Reseach Agency (AFHRA) and thier archives is here: Air Force Historical Research Agency - Home It is a bit tough to do long distance research but they do have a wealth of info there. You might need to schedule a trip!

In regard to civilian incidents - much of my knowledge is word of mouth although I am sure by looking at the NTSB reports you could find out more. I suspect this is much like one of the video links posted previously - pilot has "tons of experience" and is talking to the passenger and just plain blows it by not lowering the gear (even with the warning horn)!

Tom P.

 

[FLYBOYJ]

Quick reply - I think perhaps it is my interest to get a little beyond the pure statistics. In reviewing crash reports you might find that some accidents were the fault of missing something obvious (folded wings) and something that just plain failed (nose gear in the B-24 comes to mind). Do the statistics differentiate between "pilot/crew error" and "mechanical" for the accidents?

One incident in Wendover that comes to mind was a navigator in a B-24 who stepped on the nose gear door and fell through whereupon the plane taxiied over his leg and broke it. I would assume this is a "checklist" failure but in looking at the actual report (IIRC) it says nothing about failure to follow proper takeoff protocol. Actual interviews might be revealing on how prevailing attitudes toward the checklist were - did they care or see the value? To me it would reveal the human side to the statistics and even when the statistics say, "this was available" you might find in interviews that the truth is far from it.

A link to the Air Force Historical Reseach Agency (AFHRA) and thier archives is here:
View: https://www.youtube.com/watch?v=qpG4f3F_0Ck

 

[Matt308]

How many times...

Air Canada 767 - WTF is That Long "Bong" Aural Warning?

As they communicated their intentions to controllers in Winnipeg and tried to restart the left engine, the cockpit warning system sounded again with the "all engines out" sound, a long "bong" that no one in the cockpit could recall having heard before and that was not covered in flight simulator training.

In line with their planned diversion to Winnipeg, the pilots were already descending through 35,000 feet (11,000 m)[2] when the second engine shut down. They immediately searched their emergency checklist for the section on flying the aircraft with both engines out, only to find that no such section existed.

http://en.wikipedia.org/wiki/Gimli_Glider

 

[Jenisch]

Some days ago I had a nasty experience together with my instructor due to not have used the checklist in a glider. Will describe it.

We had just landed, and I thought I wouldn't flight anymore that day, so I realize the seat belt and started to move out from the aircraft. My instructor then said "one more flight!". I said ok, entered again and the other guys started to push the glider to the runway. In the hurry (the tow plane had just landed and they didn't wanted him to cut the engine), we just read the "line up on runway" checklist. After we read the checklist, I noticed that I was without my seat bealt. While I quickly put it and having forgot to put the bealt impressed me, I was being impulsive due to the hurry and didn't realize the mistake of not read the checklist would have other consequence. The take off then started and when the lift off speed was reached, I pull the stick back and just heard my instructor shouting "WHY PULL SO HARD?!". Then, by the way the glider was flying, I perceived what happened: elevator trim was to some degree nose up from the previous flight! (it should have been slighty nose down for take off!). Fortunately despite this, the take off and the rest of the flight went normally.

When we were already high, I even commented with the instructor of the content of this topic, and how I was irresponsable for not having read the checklist (actually it was his fault as pilot in command, but ok). We did not even commented what happened after the flight, as certainly both of us understood well the mistake that was done.

 

[bobbysocks]

even with a checklist you have to watch if you dont complete it start to finish without interruption. its scenarios like your jenisch..in a hurry and assume everything is ok....or something disrupts you in the middle and a step gets skipped that teach us valuable lessons and hopefully tragedy isnt included. it doesnt have to be only flying but following steps in making something...rebuilding or repairing an item...anything. i had a class on disasters for my job and this was impressed upon us over and over. the story they used to drive it home was the true story of a canadian helio mechanic who was pulled away momentarity from a job he was working on by a phone call. after the call he went back and picked up the next step in the process but he did not snug the bolts he had just installed on the previous one. that mistake ended tragically. their solution if an interruption/distraction happens was to back up and repeat the previous several steps or start the process from the beginning. i will tell you this is one of the most valuable things i ever learned from any course my employers made me take. following it has saved me a lot of large and small amounts of grief as i have found i would have missed things like that helio mechanic.