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Dec 25 2010

From Checklist to Checkmatrix – 2

Back in June I dive head-first into the ugly world of checklists, offering my own approach to some classic problems. Not perfect by any means, the idea worked well and the concept proved to be sound – at least from my own experience.

Obviously I am not the only one obsessed with an idea that art and science of the GA checklists creation is not in its best shape now – both NASA and NTSB were performing similar researches and case studies for the airlines since the early 90-s of the past century. It’s interesting how the checklists have matured – on one hand – and accumulated a lot of bad practices, on the other, during the 60 years of their existence…

Let me outline the most common and known challenges, surfaced during the above mentioned studies:

Actual usefulness of the checklists. Airspaces, aircrafts and all the related systems just keep on growing in complexity through the years. Even a small rental Cessna with retractable gear will have a couple times more of controls and gauges, compared to the old good Piper Cub. More complex planes are multiplying the points of pilot attention further on. Navigation systems keep evolving from cumbersome and inefficient complexity to feature-loaded modern interfaces of the “glass cockpits”.

Unfortunately, human brain is limited to keep only about half a dozen of items in the immediate memory, so when there is more to remember and manage simultaneously – overflow is inevitable. People stare blindly and try to put their thoughts together and decide what they should do next? No logical reasoning or deep thinking is possible under the merciless time and conditions pressure. There are also lots of distractions – radio work, cockpit conversations, wind gusts, unexpected noises, etc. All those add to the load of the already flooded brain, so instead of a dozen of memory items it can barely manage something like one or two at a time…

Training alleviates this problem to a certain extent – because experienced pilot knows beforehand what to expect, and instead of being alert for everything possible, he focuses his attention only on the critical areas. Unfortunately, this is not applicable to the infrequent flyers – especially those who rent multiple airplanes from different locations. There is no way they’d be flying comfortably and relaxed, pulling the memory items out of their brain with graceful timing, managing the action items quickly and efficiently.

So the need in the checklists is directly proportional to the workload – they result to be needed for both an infrequent flyer in a moderately complex environment, or an experienced pilot in a much more confined surroundings. People who fly simple aircrafts in predictable conditions (e.g.: ultralight or glider pilots, flight instructors) may easily memorize the items to check, and perform the actions needed “automatically” – but even they have to rely on their memory to be flawless. For the rest of us, checklist is not a luxury, but a safety requirement.

Quality of the checklists. Unfortunately, most of the checklists are created in the least professional manner. There are lots of cases where pilots are encouraged to create their own checklists, buy some “generic” checklists created by one or the other publishing company, or are forced to use the checklists provided by an aircraft owner or flying club. Quality of those documents may be and frequently is very substandard, which is unprofessional and dangerous! Inefficient, cumbersome and plain wrong checklists were factors in the accidents with heavy loss of life, and property damage.

Most typical problems with existing checklists are the following:

  • Unrelated, obsolete items – pilots tend to skip them;
  • Confusing terminology – like what is “check”, or “as required”?
  • No clear definition of whether the checklist items are pre- or post-conditions;
  • Mix of action and memory items;
  • Mix of technical and organizational information;
  • Checklists intruding into the basic airmanship skills;
  • Local specific information embedded in the checklist;
  • Repetitive and redundant catch-all items instead of thought through sequences;
  • Overcomplicated “training” checklists where simple aircrafts are represented as “airliners”;
  • Format, layout, typography not suitable for the actual cockpit environment;
  • Lack of the logical coherence, sequential and systematic progression through the items.

To make things even worse, many of the checklists are including the army-style mnemonics which are “checklists” by themselves, and require memory mapping and decoding at the moment of usage. What is CCCCC, or “tomato flames”? Can you spell all the items of those mnemonics immediately? Are they relevant? Should you waste your time and effort in translating such abbreviations, when entering the downwind over the uncontrolled airport, with a bunch of people in the circuit?

All these and many other requirements to the checklist quality should be scientifically studied, standardized and enforced on the publishers of those documents on the international level guaranteeing quality and providing defense against the liability claims.

Checklist design is a complex process. It involves deep and practical knowledge of the airplane it relates to, different cockpit layouts available, instruments reliability, pilot proficiency level, and even a phase of the flight. Checklist for the same aircraft may look quite differently when created for a VFR weekend renter, vs. an IFR commercial air taxi operator. Wording and format may be different, and different layouts of information could be provided to remain in sync with the pilot abilities and environment.

Airmanship requires a pilot to perform certain number of things in a certain sequence. Some of those may not have immediate effect on the flight (e.g.: transponder switch position, lights on or off) but are required to improve safety of the plane and pilot within the aerospace. Certain blocks of the checklists may happen to be skipped all together – for example a run-up section, if you have just landed, stamped your logbook and are going to fly again. Checklist should be designed to address that, and be able to guarantee the presence of critical dependencies without falling back to a cheap redundancy through a blind repetition of the items.

Cockpit layout is another constraint adversely affecting the pilot workload and tightly related to the checklist items. Current design of most cockpits is mostly useless for the natural left-right and up-down movement of the attention focus. Even the flight instruments may provide insufficient or unreliable information – classic example is the fuel gauge in a small GA aircrafts. If may be calibrated to only tell the truth when showing a “full tank” or “empty tank” indication! How should the checklist address this problem?

And most importantly, current checklists include lots of seemingly useless verbal garbage due to the lack of key criteria to use when choosing the checklist items. In my opinion, this criterion should be “safety”. If the flight safety is handicapped by not checking for certain condition, this check should mandatorily be present in the checklist. The rest may be omitted and left to the basic airmanship to take care of.

Checkmatrix – a new approach. My idea was that there are clearly identifiable areas where the pilot should focus his attention (e.g.: Engine, Fuel, Radio), and certain number of flight phases during which those checks should be accomplished (e.g.: Taxi, Cruise, Run-up). When we overlay the flight phases with attention areas, resulting layout looks like a matrix, rather than like a list.

Another important idea was that checklist should not be a substitute to the basic airmanship skills. Let’s take an example of the flaps position during the landing. If we are talking about a simple GA plane, a pilot should be able to deploy a needed amount of flaps which will permit him to make the runway at a specific airspeed under specific conditions. If he is unable to do that, a lack of training is present. On the other hand, if we are talking about a commercial airliner, flown by a group of people in a very complex environment, calls for the specific flaps setting with perfect timing become mandatory and could not be replaced by the basic airmanship.

In a sample study related to flying a typical small GA aircraft with fixed prop – something like Cessna 150 or 172 – I have identified 10 major phases of flight and 6 major areas of attention focus. I have accommodated them in a form of a matrix, where for each phase you will have to complete all the checks in each attention area, to ensure you are ready for the next phase.

You may wish to download a sample of my “checkmatrix” to get a live illustration of what I’m talking about. Please notice that this sample is not intended to be used for the actual flying, and is only provided for the educational purposes – I am not assuming any responsibility for its usage.

Memory items are excluded as a concept – if a pilot needs to memorize something and use it later, that item should surfaced as an action item when the time comes. Action items may be pre- and post-condition by themselves.  They could combine simple sub actions into a “mode” (e.g.: Carb Heat Hot and Mixture Full Rich equals to a “Slow Flight Mode”), or explicitly point to an exact attention item (e.g.: “VSI Positive” requires a visual check of the VSI indicator hand showing climb). Conditions to check must be as explicit as possible, i.e.: not “check lights ok”, but “lights operative”.

Action items are organized in the structured, consistent way, grouped by the attention focus areas and relevant to the corresponding flight phase. Pilot is forced to distribute his attention following the same, optimal sequence. Completion of all the action items listed allows the logical progress from one attention area to another. If in doubt, pilot can step back to exactly one area instead of browsing through the checklist in an attempt to find where exactly he was interrupted and what check is missing.

The matrix is perfectly scalable to fit more complex operations, and can include more conditions to check. Scalability within the concept can be ensured by complying with the following rules:

1.       Each step must be a mandatory to the flight safety condition;

2.       The steps should not dictate common actions related to the basic airmanship;

3.       Steps should be compressed to pronounce them in 2, maximum 3 syllables;

4.       Each cell of the matrix must contain only relevant and non-redundant check items;

5.       Number of action items should not exceed the amount of manageable memory items;

6.       Redundancy is provided on the flight phase level (e.g.: Run-up may be omitted);

7.       Columns drive the focus of the pilot attention in a consistent, L-shaped way;

8.       Row completion leaves the aircraft completely configured for the next phase of flight.

This is it. As simple and complex as it looks like… It takes quite a bit of practice to distribute the actions properly, but it pays back later on, when a pilot gets accustomed to distribute his attention in the consistent, organized way – which is the main advantage of the “checkmatrix” compared to the current checklists.

Another important advantage is that all of the check items are available to the pilot “at a glance”, there is no need to redirect the attention within the same checklist, flipping the pages, pulling the document out and stuffing it back. I like to place it on my kneeboard, together with a planned flight sketch and a set of critical numbers for the aircraft I’m flying.

Due to its rigid logical structure, together with a brief check items, “checkmatrix” could be easily incorporated into the digital presentation devices, such as iPad, iPhone or EFIS.

If a number of action items within a cell are aligned with the pilot immediate memory capabilities, it is highly improbable that the checks would be omitted. And it is psychologically hard to deviate from the natural flow of attention to the flight phases and focus areas in the matrix – because they are arranged in a natural “L-shaped” pattern, where the eye is moving from top-down and from left to right.

I believe that my “checkmatrix” is a definitive improvement over the current checklists. It is way more clear, organized and efficient. It also provides a good framework for the crew resource management, and may benefit even more from the more reliable and ergonomically efficient cockpits of the future.

Dec 14 2010

La Negrada Eterna

Así que Macri está desalojando las villas, que bien… Digo, bien para la gente común, que vive y trabaja sin colgarse de “planes sociales”, que paga impuestas y que siempre termina siendo robada, asesinada, asaltada por la mierda que se acumula en las villas. No es que todos los habitantes de las villas son criminales o sus familiares – algunos son simplemente inútiles. Claro, inútiles para todo salvo ser una carne de la fuerza piquetera, un instrumento que forma la base del poder kirchnerista y semejantes.

Por eso no hay duda ninguna que Cristina vaya a defender a los villeros – son millones de votos garantizados, y no le causan ninguna molestia ya que ella no anda por la calle de laburo a casa. Bah, ni siquiera pretende de tener alguna idea de cómo la pasa el resto de los argentinos. Como dijo: “El otro día miraba los diarios y pasaba páginas y páginas de anuncios de ventas, de grandes supermercados” y aquellas páginas “se caían de anuncios y eso es crecimiento”.

Ay qué lindo. Descubrir los signos de crecimiento mirando a los anuncios en un diario y basar conclusiones del estado de economía del país en eso. Que profesional. Digo, si ya caímos a ese nivel, porque no vaya a un supermercado – día al día – y compare los precios? Para cagarse de risa, nomas. Ahí va a descubrir que los precios aumentaron como cuatro veces solo en este año. Que sorpresa seria para nuestra presidenta! Ni hablar si tenga que pagar expensas, u otras cosas cotidianas – toda la vida sera una cadena de maravillas para ella, y es solo por experiencia propia, nada de diarios.

Chistes boludos afuera, hay sangre en las calles. Hay, y haya, y sigue siendo mas y mas mientras que el montonazo de la negrada porteña sigue aumentando gracias a los nuevos ocupas – bienvenidos personalmente por la presidenta, pese a los intentos del gobernador de la ciudad. No es nada abstracto: Si antes su chance de cobrar unos golpes y una pistola apuntando su panza seria uno a cien, pronto será uno a ochenta – eso sí que será un crecimiento muy notable!

Mi querida Argentina, como logras desviarte todas las veces y caer una y otra vez en un pozo del marasmo político tan feo… Puedo entender la gente que votaba y lloraba a Kirchner. Puedo entender porque votaban a Cristina (especialmente los hombres, jeje). Pero la puta madre, como no logran entender que el populismo no lleva a ningún lado? Si los precios ya pasaron por encima los valores de 1:1, y su salario esta reducido a 1:4, no se dan cuenta que las cosas siguen yendo mal, que no es una fluctuación u algo simple a corregir?

Partido Justicialista – que gran nombre, realmente no se puede no adorarlo. Justicia es lo más importante, lo que nos toca a todos… entonces por qué mierda los que la aman mas la están pisando y descartando todas las veces? Si es ilegal ocupar las tierras, matar, robar, asaltar – entonces los que lo hacen cometen la injusticia, y los primeros que deberían frenarlo son los de PJ! Sin embargo, un derechista Macri aparentemente tiene más entender y hace más para cumplir lo que es la Justicia en realidad, no de palabras baratas. Hasta tuvo que crear su propia Policía para eso, ya que existente era totalmente corrupta e inútil.

Da lástima. Da pena. Argentina merece mucho mejor que otra banda de chorros arriba abrazando los chorros de abajo con la gente – que son y serán sus víctimas – metida en el medio, es triste… Pero miren, piensan, no compran pelotudeces – hay que desalojar las villas! Hay que cumplir con la ley! Basta de disparar de espalda a la gente que los defiende! Cuantas veces más lo quieren hacer, que ya no nace ni crece alguien que quería ponerse del frente para resolver sus problemas. Si ni un millonario mafioso lo puede hacer, por más que tendria ganas. Despiertan, mis queridos paisanos – abren sus ojos, por favor…