This article was written by Geoffrey Dell, Associate Professor/Discipline Leader Accident Investigation and Forensics, CQUniversity Australia, and was first published on The Conversation. Read the original article here. The opinion of the authors does not necessarily correspond with that of the editorial team. Want your opinion to be featured on AeroTime? Send us a line at editor@aerotime.aero.


One of the issues raised in the investigation of a Melbourne (Australia) air crash that killed five people was the importance of pilots sticking to any pre-flight checklists.

Pilot Max Quartermain and four American tourists died when a Beechcraft B200 Super King Air VH-ZCR crashed into the DFO shopping centre shortly after takeoff from Essendon Fields Airport (MEB) on February 21, 2017.

The Australian Transport Safety Bureau (ATSB) report into the crash found the pilot did not detect that the aircraft’s rudder trim was not in the correct position before take-off. This rudder trim helps a pilot control an aircraft.

With the rudder trim incorrectly set, the report found, this adversely affected the aircraft’s take-off performance and ability to climb.

While not apportioning blame, the ATSB report said the rudder trim’s incorrect position was a contributing factor to the crash.

The ATSB’s chief commissioner Greg Hood said this accident emphasised the importance of having a cockpit checklist applicable to an aircraft’s specific and current modification status.

The report said it was not known whether the pilot had used a checklist on the day of the crash, but Mr. Hood added:

“In this particular tragic accident there were opportunities in the checklist that existed for the pilot to ensure the rudder trim was set to neutral prior to take-off.““““

Checklists for pilots

The use of checklists in single-pilot operations has been a contentious issue over the years. From the beginning of flight training, pilots are taught to memorise key checklists so they can readily recall and perform the required checks accurately.

In simpler cockpits, this process can provide reliable results. As the complexity of the aircraft systems and the cockpit controls increases, the inadequacy of solely relying on memory and recall becomes evident.

To minimise the likelihood of configuration errors in two-pilot airline operations, it is usual practice in each phase of flight for the cockpit to be initially configured by the pilots by recall.

The correct configuration is then checked by the two pilots by running through the applicable checklist.

The pilot not flying will usually call the item, both pilots will then check the appropriate switch or control setting. The pilot flying will verbally respond to the call to confirm the correct setting.

For a configuration error to occur in that environment, the setting has to be made incorrectly from recall, or omitted, in the first instance. Then both pilots have to miss the incorrect setting when the checklist call is made and responded to.

This method – sometimes referred to as a “challenge and response” method – provides two levels of procedural redundancy to guard against human errors that might otherwise lead to incorrect settings.

Single pilot operations

The challenge arises when considering how to achieve the same level of error-proofing in single-pilot operations. For example, a 2005 study for the NASA Ames Research Centre said: