Errors cost money, and sometimes significantly more in terms of social capital and lives lost. As long as people are involved with performing a process, the threat of human error exists. As has been demonstrated in every industry and profession, people are susceptible to making mistakes regardless of their intelligence, training, or amount of experience.
When human error in a process occurs, what actions should be taken in response? Oddly enough, it is frequently to add layers of additional complexity to the process. This complexity comes in the form of expanded instructions, additional quality assurance checks, or additional safety briefing requirements. While well intentioned, this added complexity often makes the problem worse as it becomes increasingly difficult to break out the critical information from the din of detail—critical elements are simply lost in the added noise. If the potential for human error in process performance is to be effectively reduced, complexity must be reduced as well.
The aviation industry has been engaged in the systematic reduction of human errors for almost 100 years. In 1935, a seminal event occurred during a demonstration flight of Boeing’s Model-299 aircraft. As part of the demonstration of their new aircraft’s capabilities, Boeing employed two of the most experienced and knowledgeable pilots they could find, including the Army Air Corps Chief of flight testing. However, the crew forgot to remove a control lock from the flight controls prior to taxi and crashed shortly after takeoff. The Army deemed the Model-299 too complex to operate and went in search of a different solution. However, the Boeing pilots and engineers developed a simple solution and the Model-299 went on to be designated the B-17 Flying Fortress, flying tens of thousands of missions over Europe during World War II. The Boeing solution? A checklist.
This example is often cited to demonstrate the efficacy of checklists. Unfortunately, the term of “checklist” has different meanings for different people. For many, a checklist is simply a list of steps to be followed. No thinking, just follow the bouncing ball. For others, it is a long, complex engineering procedure often too unwieldy or cumbersome to be helpful in the field. In the aviation industry, checklists are a system to reduce susceptibility to human factors (stress, fatigue, boredom, etc.), trap and mitigate human errors and increase reliability. They exist to free up the pilot’s cognitive abilities for consideration of everything that is occurring during execution, not just the explicit steps.
Successful checklist implementation requires three criteria:1. Checklists designed for the specific task by operators
2. Simple rules for checklist use
3. Deliberate leadership actions to implement a checklist culture
Checklists work because they reduce complexity for the user and act as a crosscheck during times of stress, fatigue, complacency, or other times when human error is likely to occur. The design process is a specific methodology which considers conditions of use, constraints of task execution, potential errors, and harvests practitioner expertise to drive standardization. Well-designed checklists work together to improve the reliability of an entire operation, not just a single task. Most importantly, checklists are designed to produce predictable, reliable results.
Checklists have limited use without a system of individual and team habits for their use. For example, a “Do – Verify” checklist may require the user point to or touch each individual gauge as they confirm the condition and complete associated steps. Other simple rules might include the order of precedence for checklists when an abnormal condition is encountered during execution. Again, these simple rules help reduce complexity by relieving the user of the need to navigate complex decisions on their own during times of stress, or simply by encouraging good practices.
Finally, successful change management implementation requires deliberate leadership actions at all levels of an organization and throughout the process. Leaders must communicate the vision and plan for checklist adaptation and use, prepare the organization for cultural changes, set and enforce checklist use expectations, drive standardization, correct deficiencies, and sustain cultural and process improvement gains.
The smart and well thought out implementation of a system of checklists has been key to the aviation industry’s position as the benchmark for reliability in complex, high consequence operations. The enduring checklist culture present in the aviation industry considers design for efficacy, the habits around their checklist use, and the organizational leadership to ensure effective implementation. With some forethought and a rigorous approach to design and implementation, use of checklists to help users navigate complexity will reduce human error while ensuring that your people get the job done right, the first time, every time.