The Checklist: The Checklist The Checklist The Checklist The Checklist The Checklist The Checklist
The Checklist: The Checklist The Checklist The Checklist The Checklist The Checklist The Checklist
The Checklist: The Checklist The Checklist The Checklist The Checklist The Checklist The Checklist
THE C
From that point on, Boeing played
its cards close to its chest as it liter-
ally bet the existence of the company
on the success of the program. The
Model 299 made its first flight on July
28, 1935, flown by Boeing’s chief test
pilot Leslie R. Tower.
The huge 103-foot wingspan Model
299 was an aviation bombshell, stun-
ning the flying world with its four big
engines, controllable pitch propellers,
retractable landing gear, flaps, and
provision for five .30-caliber machine
guns. Dubbed the “Flying Fortress” by
By Walter J. Boyne
as too costly to buy and too difficult The Crash of 299 went up much higher than normal. Two
to fly, the Air Corps pressed on. At about 9:30 a.m. on that October men, 1st Lt. Robert K. Giovannoli and
Then on Oct. 30, 1935, with the sud- day, the Model 299 was manned by a 1st Lt. Leonard F. Harman, sensed it
denness that characterizes experimen- very experienced crew, including Maj. was in trouble and ran forward as the
tal test flights, Boeing’s great gamble Ployer P. Hill, Wright Field’s Flying airplane reached an altitude of about
seemed to fail when the beautiful silver Branch chief, and his copilot, 1st Lt. 300 feet.
Model 299 crashed on takeoff from Donald L. Putt. Also on board were The Model 299 stalled, turned 180
Wright Field. The tragic event seemed John B. Cutting, a flight-test observer; degrees, and fell back onto a field. It
certain to lead to the cancellation of the Mark H. Koogler, also from the Fly- landed on its left wing, cushioning the
program and an immediate change in ing Branch; and Tower. Hill was an impact, which probably saved the lives
Army Air Corps planning. experienced test pilot, having flown the of several crew. Lying flat on the field,
No one then could have guessed that earliest versions of the Martin B-10. It the bomber burst into flames. Amaz-
with a little clever management and a was his first flight in the Model 299. ingly, four crew members were able
dose of politics, the program not only Tower was positioned behind the two to crawl from the blazing wreckage.
would be salvaged, but the accident pilots, ready to give advice. Putt and Tower emerged from the
would bring a long overdue idea into Observers described the initial run cockpit area, while Cutting and Koogler
existence: the checklist. of the Model 299’s takeoff as normal, got out from the rear. Giovannoli rushed
The checklist ultimately would alter even though it broke ground at about into the fire to find Hill jammed behind
the way aircraft were tested and flown 74 mph in a “tail low” attitude. As its the controls. Harman crawled in and cut
around the world. speed increased, the bomber’s nose Hill’s shoe off, freeing him from the rud-
AIR FORCE Magazine / August 2013 53
USAF photos
The cockpit of Model 299. The controls were not ergonomically designed. Right:
Boeing’s bombardment airplane in pieces at Wright Field, Ohio, in 1935. The crash
killed two crew members and destroyed the airplane.
der pedal. Giovannoli handed Hill out it contained the cause of the accident:
of the cockpit into the arms of Barney an internal control lock that controlled
Miller, an employee of the Martin Co., both the elevator and rudder. There
but Hill died later from his injuries. were three positions for the elevator control yoke, the small elevator trim tabs
Tower, also grievously injured, gave on this lock. Two of these were “up”; moved to the up position, contributing
testimony about the accident and ap- one was “down.” to the nose-up attitude. Tower said he
parently blamed himself for the crash. made an attempt to unlock the controls
He, too, died not long afterward from Enter the Checklist when he realized the situation, but could
the injuries sustained in the accident. The board concluded that the eleva- not reach them.
A board of officers convened at tor control could not have been in the The board stated that—due to the size
Wright Field to investigate the crash. extreme up position, because at that of the airplane and the inherent design of
The presiding officer was Lt. Col. Frank position the control yokes would have the control system—it was improbable
D. Lackland, for whom Lackland AFB, been inclined back at an angle of 12.5 that any pilot, taking off under the same
Tex., was later named. The board de- degrees, and the pilots would not have conditions, would discover the locked
termined the accident was “not caused been able to climb into their seats with- controls until it was too late to prevent
by”: structural failure; malfunction of out releasing the controls. They also a crash. Ordinarily, pilots make checks
flight controls, engines, or propellers; deduced that it could not have been in of their movement as a precaution, but
the automatic pilot; or any faulty struc- the down position because the aircraft apparently this did not occur.
tural or aerodynamic design. Instead, it would not have been able to take off. In the aftermath of the Boeing Model
ascribed the direct cause to the elevator Further, the Pratt & Whitney repre- 299’s crash, the Air Corps declared
control being locked. sentative, Henry Igo, had conducted Douglas Aircraft Co. to be the winner
This is, by implication, a “pilot er- the engine run-up with the controls of the multiengine bomber competition.
ror” verdict—but the board did not say locked in the first up position. This Douglas’ DB-1 was redesignated the
that directly. The board’s determination meant the pilots could have initiated B-18 and later given the name Bolo.
was based on a detailed analysis of takeoff without realizing the controls Some 350 were built, and they gave
the flight-control mechanism and the were locked. The flight would have excellent service—but not in the long-
testimony of Tower and Putt on how the seemed normal until they increased range bomber role.
aircraft behaved in the air. This assess- the speed, which would have affected The Air Corps still wanted B-17s, and
ment was corroborated by eyewitnesses the locked control surface, forcing the Boeing received a consolation prize, a
on the ground, many of whom were aircraft’s nose up into a stall. contract for 13 aircraft designated Y1B-
experienced airmen who watched the Both Tower and Putt believed the 17. Still, the Air Corps faced arguments
flight from takeoff to impact. control was locked. that the aircraft was too big to handle.
The tail section of the aircraft was The investigators concluded that The Air Corps, however, properly
virtually all that survived the fire, but when the pilot pushed forward on the recognized that the limiting factor here
54 AIR FORCE Magazine / August 2013
was human memory, not the aircraft’s accessible. The checklist must have all neutral; mixture: rich; pitch: fine; and
size or complexity. the necessary items from engine start flaps. This was used to preflight every-
To avoid another accident, Air Corps to engine shutdown, including emer- thing from a Tiger Moth to a Lancaster.
personnel developed checklists the crew gency procedures. But it is impossible The creation of the checklist was
would follow for takeoff, flight, before to remove the human element—errors delayed by an unrealistic reliance
landing, and after landing. still occur. on the memory of pilots. This dated
The idea was so simple, and so effec- all the way back to 1903, with the
tive, that the checklist was to become the Forget Memory Wright brothers’ intimate knowledge
future norm for aircraft operations. The Today the checklist can take several of airplanes. The precise care and or-
basic concept had already been around forms, including paper, a scroll giving ganization of their preflight techniques
for decades, and was in scattered use in line by line actions, and various me- often was commented upon at the time,
aviation worldwide, but it took the Model chanical types, some involving a voice particularly in the demonstrations
299 crash to institutionalize its use. presentation. Modern glass cockpits use Wilbur Wright conducted in Europe.
According to the Merriam-Webster different methods, including a computer- Audiences for his flights sometimes
dictionary, the term “checklist” first based text on the display screens and became restive with his deliberate, un-
appeared in 1853. There is no mention even electronic checklists that sense hurried, and comprehensive checks of
of its specific use, but the need for it in the state of a system. the aircraft, catapult system, weather,
operating heavy machinery or railroad The paper checklist has been the and everything else.
equipment is obvious. Some similar most common. Wilbur knew well that if something
types of reminders probably have been Aircrews can either “run a checklist,” could go wrong it would, and he took
in use for centuries for complex tasks. where each item is called out and the his time to be sure to prevent a mishap.
One current formal definition has action or status is reported in reply, or This same philosophy has endured
special meaning for anyone who has they can configure the aircraft from through the years, both before and after
made a wheels-up landing. It says that memory then use a checklist to verify checklists became commonplace. It was
a checklist is an “informational job aid that all the steps have been taken. the pilot’s responsibility to ensure the
used to reduce failure by compensating There are great improvements over aircraft is ready for flight.
for potential limits of human memory the earlier mnemonic checklists. These Still, this approach does not result
and attention.” varied from the familiar “GUMP” check in uniform success. Aircraft accident
Checklists are intended to be used for the gear, undercarriage, mixture, and reports are replete with findings that
precisely. Every certified aircraft has to propeller to the Royal Air Forces’ war- the failure to use a checklist properly
have an approved cockpit checklist easily time “TMP and Flaps,” i.e., trimming: resulted in an accident.
AIR FORCE Magazine / August 2013 55
not surprising that the Royal Flying
Corps—and its successor, the Royal Air
Force—created the closest ancestors to
the modern checklist.
The nearest relative to a post-1935
checklist is found in “Hints on the
Bristol Fighter,” dated March 30, 1918,
and written by the officer commanding
No. 39 Squadron. The section head-
ings are similar to modern checklist,
including specific sections designed
to ensure pilots see that the pressure is
holding, the ignition is fully advanced,
the temperature is at least 65 degrees
and not over 85 degrees, the oil pressure
is OK, the blinds are open, and the tail
lever is forward.
In 1919, the Director of Air Service
published “General Rules to be Ob-
served at all US Flying Fields.” This
order listed 33 items vital to the safe
operation of aircraft. In the same year,
Capt. Benjamin Foulois at the controls of a Wright military biplane in 1911. the Royal Air Force Air Publication
Foulois advised preflight actions that resemble today’s checklist procedures. 129 stated that a pilot should always
carry out his preflight walk-around
“systematically in order that no part
Like the Wrights, Glenn H. Curtiss instructions on the inspection of every may escape notice.”
began a pilot training program to en- element of the aircraft, from the correct Even by 1937, two years after the
hance the sale of his aircraft. In 1911, tension of wires to the proper inflation Model 299 crash, RAF instructions
he established a flying school at North of tires. still depended on memorization for
Island, Calif., where Lt. Theodore G. their execution. They were much more
Ellyson, the Navy’s first aviator, was Hubris, then Accidents precise, offering checks that had to
among his students. Although articles By 1918, with vastly expanded pilot be accomplished before each stage of
on the school mention that Curtiss training in the United States, a special flight, but pilots were “required to learn
demanded a checklist be made for his handbook was created by Curtiss for the drill” rather than have something
students, there is no hard evidence of the JN-4 “Jenny.” One section was titled written in hand.
such a checklist. “Hints on Flying” and provided a list of It should be remembered that cockpit
During the same year in San Antonio, 18 items, each with considerable detail. ergonomics were not a big consideration
a young Benjamin D. Foulois wrote the Five items were devoted to actions to anywhere at this time, and the placement
“Provisional Aeroplane Regulations for take before takeoff, nine covered in-flight of even such basic controls as throttle,
the Signal Corps.” In it he wrote, “Im- procedures and safety precautions, two mixture, and propeller varied from type
mediately preceding every flight, an advised on landings, and two discussed to type.
aeroplane will be carefully inspected ways to avoid stalls and spins. The general attitude within the US
by the pilot and mechanic. Each in- While not a handheld checklist that Army Air Forces continued to be, “If it
spection is to be made independently was carried in the cockpit, it was a manual has a stick and a throttle, go fly it,” but
of the other. Upon completion of both that contained all the advice necessary increasingly after 1935 paper checklists
inspections the mechanic will report the for the operation of the aircraft. It also were more available, particularly on
result of his inspection to the pilot; the set a pattern for the future around the multiengine aircraft.
pilot will then report the result of both world—most air forces would depend The success of aviation checklists
inspections to the senior officer present on the appropriate flight manual to be led to their adoption by many other
on aeronautical duty.” an adequate source of knowledge. disciplines, including the quality as-
While not a checklist in the modern As was the case with all of these check- surance for software engineering, in
sense, Foulois’ instructions have the list predecessors, pilots were expected civil litigation, and even in tracking
challenge-response element of today’s to know the manual by rote. Sometimes and evaluating sports card collections.
procedures. this led to hubris, which led to accidents. So as tragic as the Model 299 Wright
Other training schools recognized Given its wild expansion from a Field crash was, it almost unquestion-
the need for systematic care in operat- handful of aircraft in 1912 to the larg- ably has saved thousands of lives over
ing aircraft. Sometime in 1915, engi- est air force in the world in 1918, it is the ensuing decades. n
neer George E. A. Hallett developed a
checklist-like procedure for the Army Walter J. Boyne, former director of the National Air and Space Museum in Wash-
at North Island. Hallett went into much ington, D.C., is a retired Air Force colonel and author. He has written more than 600
greater detail than Foulois. The docu- articles about aviation topics and 40 books, the most recent of which is How the
ment, “Inspection of Aeroplanes Before Helicopter Changed Modern Warfare. His most recent article for Air Force Magazine,
Flight,” included extremely precise “C-124 and the Tragedy at Tachikawa,” appeared in the July issue.
56 AIR FORCE Magazine / August 2013