In 1987 Northwest Airlines Flight 255 was taking off for a flight from Detroit to Phoenix. The airliner lifted off the runway, but the plane rolled back and forth and was unable to gain enough lift for flight. Within seconds, the plane had struck a light pole severing it’s left wing tip and igniting engine fuel. It then crashed into a nearby highway, barreling into an overpass killing 154 passengers and crew. The only survivor was a 4 year old girl whose entire family was killed in the crash.

Upon investigation of the crash, the NTSB found that the plane’s wing flaps were never extended, reducing the plane’s chances of gaining lift off the ground to zero. But why were the flaps not extended? Surely, the 2 experienced pilots would not have forgotten such a crucial step in the take off procedure. Upon further investigation of the flight’s data recorder and voice recorder it was discovered that the pilots neglected to run a crucial taxi checklist before takeoff that included the extension of the flaps.

This crash as well as a nearly identical crash 1 year later of Delta Air Lines Flight 1141 would lead the NTSB to ask for a re-evaluation of the airline industries checklists. They enlisted the help of one of the most strenuous practitioners of checklist procedures, NASA.

NASA expert Asaf Degani investigated the current checklist procedures and took part in over 140 hours of flights to personally see how checklists were conducted. He then wrote a report on his findings and recommendations citing many inefficiencies in the way checklists were written and being conducted. In 1987 pilots were required to run a series of checklists during several scenarios. The most common checklists were written on paper cards that were then followed through vocally one by one by pilot and co-pilot. Degani found several disadvantages to the use of a paper checklist.

The main one is the lack of a pointer to distinguish between accomplished and non-accomplished items. Other disadvantages are the lack of a memory system to store unaccomplished items…Paper checklists can also be difficult to read at night in low levels of cockpit illumination.

At the time, Degani also evaluated the only airplane to have a computer checklist system installed, the Airbus A-320.

The advantages of a computer-aided checklist, regardless of whether or not it is integrated to the
feedback loop, are quite obvious. The device aids the pilot by providing a pointer, storing skipped
items, and eliminating the need to occupy one hand in holding the checklist card.

In the end, Degani offered several recommendations for the airline industries checklists including:

• Subdividing long checklists into smaller task-checklists or chunks.
• Having the most critical items on the checklist be listed as close as possible to the
  beginning of the checklist.
• The use of hands and fingers to touch appropriate controls, switches, and displays while
  conducting the checklist.

So, why am I talking about an airline accident and investigation that happened 35 years ago when the recommendations for reducing further accidents were so clearly defined? There are still deficiencies within the airline industries checklist procedures made evident by Spanair Flight 5022 crash 21 years later in a Madrid airport. The reason for the crash was the pilot’s failure to conduct the taxi checklist and therefore not extend the wing’s flaps. Coincidentally, 154 people also died in this accident.

Many industries today still rely on paper checklists to follow procedures that could help in the prevention of loss of life and injury. Degani spoke to the culture of these industries as playing a large part in why paper checklists are still so heavily relied upon.

In most cases, the checklist philosophy-of-use is the outgrowth of the company’s corporate  “culture.” This term includes many factors that contribute to the overall operational concept of the organization, including management style, supervision concepts, delegation of responsibilities in the chain of command, punitive actions, etc.

With the advent of new technologies today like handheld and tablet devices, there are many reasons why companies today should work towards instituting electronic checklist systems and procedures. These electronic checklists will give proper feedback to users on tasks performed, allow for returning to skipped questions, and give instant over site to management and superiors on checklists performed.

Learn about InspectAll’s electronic forms and checklists application for iPhone and iPad.