Never Again

Skipping checklist items

December 1, 2003

In 1991 I was flying for an air taxi operator located in Fairbanks, Alaska. We provided scheduled service for mail, freight, and passengers from Fairbanks to outlying villages. One wintry morning I was slated to leave Fairbanks at 8:30 and stop at the Indian Mountain Air Force Station, then proceed to the Athabascan native villages of Hughes and Huslia, before returning to Fairbanks. The load this morning was three passengers for Hughes and one first-class mail sack for each of the three stops. In Alaska there is an endless supply of goods going outbound to the villages, so takeoffs from home base at anything less than maximum gross weight are unimaginable. The Piper Navajo Chieftain would be grossed out with soda pop bound for the Hughes village store this morning. The weather was predicted to be VFR with temperatures in the single digits below zero degrees Fahrenheit and light winds from the northeast.

I went out to the airplane and verified that the engines were warm by sticking my hands under the engine covers and feeling for heat. If the cowlings felt warm then I knew that the hot-pad heaters had been working all night. Next I crawled into the cabin to see that the wool blanket was still draped over the glareshield and listened for the little electric heater. The instrument panel was warm and ready. The day was starting out well.

A call to Indian Mountain revealed that the wind at the base camp was from the northeast at 20 knots and in the same direction at 35 knots at the radome on the mountaintop. One of my passengers asked if I could stop at Hughes first. This would require some backtracking so I apologetically said no. Many Hughes residents did not like to stop at the "scary" Indian Mountain strip.

The approach plate indicates that the runway at Indian Mountain has a 6.7-degree upslope, and a note says a successful go-around is improbable. The airstrip is located in a canyon that slopes up toward the 3,400-foot peak of Indian Mountain. The base of the strip is at an elevation of 930 feet and the parking area at the other end is at 1,220 feet.

The flight to Indian was uneventful. I could tell by the groundspeed on my GPS that, indeed, there was a good breeze out of the northeast. After many trips into Indian Mountain in the Chieftain I had become comfortable with the airstrip. A quick call to base camp confirmed that the wind was still about 20 knots. I would be landing uphill in a 20-knot tailwind. They also mentioned that there was a Lookheed C-130 Hercules on the parking pad this morning. I reassured my passengers, telling them that there would be some turbulence on approach. They reacted by shoving their handbags under their seats and giving me glum looks. The landing went OK, and as we came up onto the two-acre parking pad I saw that the Herc was in the midst of something akin to a fire drill with a front loader, pickup trucks, and numerous personnel dashing all about. I would have to park closer to the edge of the parking pad where it breaks over to the descending runway. The wind at the top was slightly off runway heading, so I decided to park near the edge facing down the strip. While waiting for the engines to cool a bit before shutdown, I set the parking brake.

The parking brake can give you fits when operating on snow. The brake disks get hot as you taxi, while bits of snow get on the brakes and melt to become water. Then you stop, set the brake, and unload your passengers. As the temperature is minus 10 degrees F or so, any moisture that was on the brake pads quickly turns to ice. Attempting to free the brake pads with power could be very exciting, as it may require several hundred horsepower and be successful on one side and not the other. Thus the Chieftain came equipped with a one-pound rubber hammer used to bang on the brake caliper before starting the engines in the hope of breaking the frozen bond between the brake pads and the disks. A longtime bush pilot taught me the following technique:

Do not touch the brakes, but rather taxi along slowly; the brake disks should cool in the slipstream. Retard the throttles, make wide turns, let the plane come almost to a stop without brakes, then rack the nosewheel steering to one side (toward the upslope if there is one). Alternatively, drag the brakes while taxiing and get them hotter than the brake disks of you know where. Now the moisture will run off as the disks will remain warm for some time. In any case, avoid setting the parking brakes in all but the most dire need.

I knew I would not be able to resist the temptation to set the parking brakes with the plane facing down the steep incline. Taxiing slowly in a wide semicircle, feet off brakes, I waited while the slipstream of the idling engines cooled the disks, then shut down and set the parking brake.

The gentlemen stationed at Indian Mountain were always happy to get their green mail sack as it contained the material that was their spiritual salvation at that outpost. After handing over the mail I climbed back in, reassured the Hughes passengers that their stop was minutes away, and began my time-tested "crank up and go" procedure. I did not notice the extra bit of power needed to coax the hesitant main wheels over the frozen edge of the parking pad. Skidding down the icy incline into a stiff breeze, the Chieftain became airborne easily, giving me no hint of my blunder.

It only took six minutes to fly around the west side of the mountain to the snowy runway at Hughes. As the plane touched down at Hughes it veered violently to the left, then to the right. In desperation I pounced on both brakes and skidded down the runway. Directional control was wild, but the landing "roll" was over soon. After stopping I took my toes off of the brakes and throttled up to see what taxiing would be like. The Chieftain would not respond.

Then I realized my sin. The pre-taxi checklist on my lap shows: Parking brake...release. In the villages there is no taxiing, because you're already sitting on the end of the airstrip. It had become common practice to skip a column or two of checklist items. I had modified my procedure to fit a particular situation and it had plunged me into trouble.

All this dawned on me as I sat in the middle of the runway at Hughes. With my heart rate still at Mach 2, I took a deep breath and, without looking down, reached below the control yoke shaft and pushed home the brake lock T-handle.

I had allowed the barbed wire of special procedures for special circumstances to get wrapped around the axles of standard operating procedure. I began slowly taxiing as my mind raced to devise a cruel and painful self-inflicted penitence.


Brian Thompson, AOPA 39590503, is a flight instructor and airline transport pilot with 13 years of Part 135 experience in Alaska. He has more than 10,000 hours and owns a 1940 Piper J-3.


"Never Again" is presented to enhance safety by providing a forum for pilots to learn from the experiences of others. Manuscripts should be typewritten, double-spaced, and sent to: Editor, AOPA Pilot, 421 Aviation Way, Frederick, Maryland 21701; or sent via e-mail to neveragain@aopa.org.


An original "Never Again" story is published each month on AOPA Online ( www.aopa.org/pilot/never_again/), and you can see an index of "Never Again" articles published in AOPA Pilot ( www.aopa.org/members/files/pilot/idxna.html). Additional information on checklist procedures is also available on AOPA Online ( www.aopa.org/pilot/links.shtml).