The Importance of Checklists: 4 Accidents That Checklist Use Could Have Prevented


Photo 1981 by J-E Nystrom, Helsinki, Finland/CC 3.0

It’s human nature to be complacent. We’re all lazy, right? But aviation isn’t an industry that welcomes complacency, and even the slightest oversight on behalf of a pilot in command can mean the difference between a successful flight and an unsuccessful one.

My flight students get tired of me reminding them about checklists. Before we even get into the airplane, I can often be heard saying: "That preflight checklist is there for a reason." And on downwind, every single time: "Before Landing Checklist." Some people understand the tedious nature of checklists and accept it; others defy it.

Why don’t pilots use checklists? Probably because they don’t expect anything bad to happen when they don’t. After all, they’ve skipped a checklist- er, many checklists - before and nothing bad happened. Maybe they remember all of the items, after all. Or maybe it’s true that 999 out of 1,000 times, a forgotten checklist item still results in a successful flight, which reinforces the pilot’s belief that it isn’t complacency, but skill, that gets him back on the ground safely. Unfortunately, this couldn’t be more wrong.

We’d all like to think that we’d never end up crashing because of a forgotten checklist item. But here are a few examples of average pilots who failed to accomplish checklist items or otherwise got into trouble for a checklist-related item. We’re not any different. We’re not immune. At the very least, it’s embarrassing to end up like one of these pilots; at the worst, fatal. If using a checklist can potentially prevent you from embarrassment or death, shouldn’t we just use it?

Here are four accidents where proper checklist use would probably have prevented the accident entirely:
Gear Down and Locked
As seen on YouTube, the pilot of this Piper Aerostar twin-engine airplane landed without gear at Aero Acres Air Park in Port St. Lucie, Florida. And then, to everyone’s surprise, he took off again. You can see from this video that the airplane is coming in too fast and unstable, and the pilot decides to go around only after touching down. Unfortunately, the pilot not only forgot the gear, but he forgot his go-around procedures. The pilot claims that he intended to go around, retracted the gear and all of the flaps prematurely and sank to the runway. Once airborne, the pilot is said to have flown the aircraft all the way back to his home in Ft. Lauderdale- about 100 miles.

This is only one report of many, many gear-up landing situations. Pilots: Don’t forget your GUMPS checklist!

Flight Controls Free & Correct

Earlier this month, the NTSB released an animation highlighting the crash of a Gulfstream IV in Bedford, Massachusetts last year. The aircraft skidded off the runway after a failed rejected takeoff, killing seven people on board - two pilots, a flight attendant and four passengers. The reason for the crash? Failure to check that the flight controls were free and correct before takeoff, and subsequently failing to expedite a rejected takeoff once they determined the problem.

The NTSB report states: "A review of the flight crew’s previous 175 flights revealed that the pilots had performed complete preflight control checks on only two of them. The flight crew’s habitual noncompliance with checklists was a contributing factor to the accident." Sadly, seven lives were lost because basic checklist procedures were not followed.

Water Contamination
There are several ASRS reports from pilots who have lived through off-airport landings due to engine failure. Many of these emergency situations are due to engine failure from fuel starvation. In many of those cases, water contamination was the culprit. In this ASRS report, a man describes his lackadaisical preflight habits after his Grumman Tiger engine quits due to water in the fuel tanks:

"Although I did not discover the water prior to takeoff, I have learned a valuable lesson. I feel that I had gotten complacent in my approach to the pre-flight in that I never found condensed water in my tanks before due to keeping them full at all times." He admits to failing to sump the fuel carefully to check for water.

Got ATIS?
In the early days of flight training, it might not be apparently obvious why a student’s flight instructor emphasizes the importance of getting a current altimeter setting. If the flight is conducted in VFR, the altimeter can be off by 100 feet and it might not matter much. It’s not until a pilot flies an approach to minimums that he realizes the value of setting the altimeter correctly. Being 100 feet lower than you intend when you’re descending on an approach can mean crashing into the runway or just short of it.

Knowing how an altimeter works and accounting for altimeter error will only keep you out of trouble if you set it correctly. We’ve all heard stories of pilots being to low or too high during an approach into IMC. This compilation of NASA ASRS reports tells how altimeter errors can lead to altitude deviations, traffic separation violations and landing accidents.

The NASA report states, for example, that, "A helicopter accident resulting in four fatalities was attributed at least in part to an incorrectly set altimeter during a period of known low barometric pressure. The report from the Canadian Aviation Safety Board states: ‘The helicopter was being used to transport personnel to work sites across a large frozen lake. An approaching low pressure area with snow and high winds...reduced visibility to near zero in some areas. The pilot most certainly encountered adverse conditions and altered course to circumvent the worst areas. The aircraft was later found...wreckage was widely scattered. The altimeter showed a setting on impact of 30.05; the correct setting would be about 29.22, causing the altimeter to read about 800-850 feet high. The altimeter had obviously been set two days previously [apparently during a time of high barometric pressure-Ed.].’"

Incorrect altimeter settings can be fatal. Checklist procedures should always include getting the current altimeter setting occasionally during flight and always before landing.