Recommendation R20030008

Recommendation issued to: Saab Aircraft AB

Recommendation details
Output No: R20030008
Date issued: 26 February 2004
Safety action status:

Output text

Safety Recommendation

The Australian Transport Safety Bureau recommends that Saab Aircraft AB redesign the Saab 340 abnormal and emergency checklists to improve usability, with reference to current human factors research findings on the use and design of aircraft checklists.

Initial response
Date issued: 18 August 2004
Response from: Saab Aircraft AB
Action status: Monitor
Response text:

Saab Aircraft AB has advised the ATSB that they issued Operations Newsletter number 3 on 4 June 2004.

That newsletter described two recent events where crews failed to identify an electrical malfunction promptly and correctly, resulting in a low voltage on one side of the system. The newsletter made some recommendations as to how to address low voltage conditions.

ATSB Note: Although the Saab response does not directly address the ATSB recommendation, the positive safety action provided by the newsletter is acknowledged. The ATSB will continue to seek a Saab response to the issue raised in the recommendation.

Further correspondence
Date issued: 30 August 2005
Response from: Saab Aircraft AB
Response status: Closed
Response text:

Saab Aircraft has carefully considered this recommendation and come to the conclusion that the effect of an improvement in the checklist would not exceed the deterioration caused by having to re-educate the crew. The fact that during over 12 million flights only a handful has lead to an incident like this one supports this statement. Since October 2004 EASA has mandated the installation of the modified GCU (Mod 2533), see appendix 1, that would automatically put a failed generator off line and prevent the battery to be drained. This will reduce the use of this checklist.

Furthermore Saab Aircraft has since the beginning of 2004 implemented a more extensive investigation of all events reported to us. In a weekly meeting, with participants from engineering, pilots, flight procedure responsible, technical services and airworthiness headed by chief engineer, all events are classified and checklist considerations evaluated. With this Saab Aircraft believes the safety aspect and human factor interface is taken care of in a more efficient way.

Last update 03 April 2012