"Not to put too fine a point on it but, including a pre-takeoff checklist item 'canopy latched??' should cure this issue once and for all." [Emphasis added]

 

Let's put this single pilot check list falsehood [emphasis added] to bed once and for all, and do it based on tests with real world data collected over many years.

 

Time for some real world data regarding human performance.  I learned this from extensive work on production line quality control in high tech manufacturing.  If you take a person in a good environment (temperature, lighting, sound)  and that person does a task for which they are trained, experienced, and have the right tools such as assembling a complex piece of machinery, on average (40 hour work week, Monday through Friday, all year round), the error rate in a simple task such as installing a screw to a required torque as you do so is....

 

About 1%.  That is, the measured error rate, over time for a trained and experienced person doing a simple task is about 1%. 

 

This has been verified in airline cockpit tests, production lines and many other environments, and seems to be a rough constant for human beings doing repetitive tasks.  For some people having a very good day, it may be a fraction of that rate.  For others, harried, tired, end of shift, it may be much more.  But figure roughly once per hundred small tasks, an error occurs, averaged over a long period under a variety of conditions.

 

Same applies to a SINGLE pilot running a check list.  Some days you will make NO errors on a 20 item check list.  Other days, tired, harried, distracted, you will make a mistake.  The most common mistake: you miss the checklist item.

 

Bingo, you are tired, in a long line of traffic waiting to go, hot day, canopy open to stay cool, suddenly you are "cleared for take off without delay" and forget the check list item.  For most items, no big deal, the airplane flies.  For the canopy, maybe, just maybe, missing the item on your Legacy means you die. 

 

This is the reality of human beings and some of our aircraft, so the record clearly shows.

 

So what to do?  On the production line, standard practice for "six sigma" quality (one error per million operations) you do the following, standard operating procedure:

 

1) Do the task.

2) Go back and check your work referencing the assembly task list.

3) When you pass the assembly to the next guy in line, he/she checks your work, and then proceeds with the next stage of assembly.

4) People rotate positions so you know you will check his work today, but he will check your work tomorrow.

 

Error rate is then 1% of 1% (the check) of 1% (checking the check) which yields one error per million.  Desired result achieved.

 

Now look at an airliner cockpit.

1) Check list item called out

2) Check list item repeated by 2nd person

3) Check list item accomplished with call out

4) Confirmed by first person calling out who does not move on until the correct challenge and response are obtained.

 

Error rate: one per million.  Or less.

 

Now look at YOUR cockpit.

 

1) As you go down you check list, you get to item X, and miss it.  Chance of it happening is 1%

2) You proceed to the next item, not knowing you have missed the item.

 

Overall error rate: 1%.  Repeat 20 times for your 20 check list items.

 

Your error rate, compared to the target rate of one per million, IS AWFUL.  Average single pilot alone operating as an individual in his cockpit without internal checking and observer operates at this level.

 

Not every day.  Not every flight.   But on average, year in and year out, you will miss a check list item 1% of the time.

 

And you could die as a result depending on the item missed and its consequences.

 

NOT GOOD ENOUGH.

 

So what is needed is a  FAIL SAFE method of protecting you from the fact that you are a human being.  If you miss a check list item and it could kill you, you need ADDITIONAL LAYERS OF DEFENSE to assure an adequate level of safety. 

 

A virtually perfect defense on a Legacy canopy is a secondary safety latch that automatically prevents the canopy popping up if the main latch is not secured (auto hood safety latch concept).  John Smith's analysis showed that conclusively.  (Plug for John's work: he has worked safety issues in the off-shore oil and gas industry.  Remember Piper Alpha.  Much was learned from that and other accidents.)

 

Otherwise you are working with layers of imperfect defenses: your own secondary check (push canopy up automatically, muscle memory), audible alarm (different sensory input) warning light (easy to miss with sun behind you), big warning message across EFIS display (hard to miss when you look at air speed indicator prior to rotation) or whatever rings your chimes. These provide vast improvements because they catch you when you miss. Most of the time. They add layers of defense, and reduce the probability  of a fatal miss from parts per hundred to down to parts per million

 

Yes, we should all be good boys and girls and always run our check list, every item, ideally with somebody challenging our work.  In reality, we are human and the environment (outside and inside your body) sometimes interferes, and you make errors.   Guaranteed.

 

If it means your life, a checklist is NOT good enough if a missed item leads to a condition that is unrecoverable.  DO NOT mislead yourself in thinking that it is. History has proven that checklists without discipline and challenge are not good enough.  Humans make mistakes.

 

Fred Moreno

 

PS

 

Recommended for retractable landing gear planes:

 

1) Check three greens when gear extended - don't take your hand off the handle until you see them . That can be a powerful check by itself. 

2) Three greens on base.

3) Three greens on final.

Overall error rate: one per million, until you are distracted.  So when distracted internal alarm bells should go off.  Then you can stay near one per million, not one per hundred.