Those lucky enough to visit the magnificent National Museum of the United States Air Force at Wright-Patterson AFB in Dayton, OH, marvel at the superbly restored aircraft of past generations that lay testament to man’s innovative spirit. Among the facility’s national treasures, one plane’s star shines brighter than all the rest.
It began life as the Boeing 299 and took flight at the same Ohio air base on Oct. 30, 1935—in prototype form—as part of a competition between the Boeing, Martin and Douglas aircraft companies. On the line was an immediate USAAC (United States Army Air Corps) order for 65 bombers. The 299 was considered a “shoe-in” to win the contract. After all, it was bigger, faster, had twice the number of engines (4) and twice the range of the competition and could carry five times the requested payload.
As the 299 was the most technically advanced aircraft of the day, Boeing relied on its veteran test pilot, Major Ployer T. Hill, to impress the military brass that October day. Things looked good (at first): The plane took off smoothly and rose sharply to 300 feet, then it suddenly stalled, lost control and crashed, killing Hill and one of the other five crewmen on board. Because of this, the 299 did not complete the competition requirements and was disqualified.
A subsequent investigation revealed the cause of the crash as a simple pilot error—the vastly experienced Hill had forgotten to release a new locking mechanism on the rudder and elevator controls. While that in itself was newsworthy information, the innovation that resulted from it helped to change not just the aviation industry but the course of modern history.
Normally, a crash like that of the 299 would lead to a more thorough pilot-training program. Boeing chose to take an innovative approach to the problem, one that simplified the training process while simultaneously overcoming any pilot ineptitude or ignorance, through the development of a simple aviation pilot checklist. Due to the complicated nature of the 299, the checklist ensured that future pilots would go through the same exacting preflight, taxiing, takeoff and landing processes every time the aircraft flew. This checklist procedure continues to be used on every plane flying today—aircraft infinitely more complex than models of the 1930s!
Interestingly, despite Boeing’s—and the U.S. military’s—disappointment over the crash of the 299, the Army was impressed enough to take an innovative look at its bidding-process rules and found a loophole that led to the purchase of 13 of the aircraft for evaluation purposes. This, in turn, resulted in the aircraft going into service a short while later under its new name: the B-17 “Flying Fortress,” arguably the greatest bomber in aviation history. We all owe a debt of gratitude to the almost 13,000 B-17s and their crews that flew over Germany and the Far East during World War II. They not only helped make the world a safer place, they left a checklist legacy that continues to look out for the safety of anyone who travels on a plane, military and otherwise.
From planes to medicine
In a recent book, The Checklist Manifesto – How to Get Things Right, Dr. Atul Gawande details how he pioneered the “Safe Surgical Checklist.” It’s an intriguing read.
The practice of medicine (and surgery, in particular) is a highly complicated, very organized activity requiring a complexity of knowledge that too many times has resulted in avoidable failures—i.e., usually patient death.
In his role as head of the World Health Organization (WHO) “Safe Surgery Saves Lives” program, Dr. Gawande was tasked to reduce avoidable hospital deaths. His book explains how he chose to model his solution, a simple pre- and post-surgical checklist, based on the aviation model. In fact, he used the same type of thinking and methodology adopted by that industry fol-lowing the Boeing 299 crash over 75 years earlier.
The result? He credits use of his simple, innovative checklist tool for the dramatic reduction in hospital and surgical deaths since its introduction in 2009, regardless of hospital conditions.
(Editor’s Note: Dr. Gawande’s checklist can be viewed at www.who.int/safesurgery .)
Secrets of effective checklists
When dealing with highly trained individuals such as pilots, surgeons and maintenance pros, the very idea of working with and adhering to a checklist may seem preposterous. (According to Dr. Gawande, many medical professionals view the use of such a simple tool as embarrassing.) Overcoming this type of bravado and misguided thinking requires a checklist to be written in a manner that doesn’t challenge or insult those who are expected to use it.
According to Daniel Boorman of Seattle, WA—the person who has been in charge of developing aviation checklist manuals for all of Boeing’s planes over the past 20+ years—the secret of a good one is in how it’s written. Using simple and precise language that is familiar to a profession, a checklist doesn’t have to be too comprehensive to be effective (usually between five and nine items). A well-designed checklist fits the flow of the work, encourages the user to read each point out loud and allows him or her to detect potential failure, prior to occurrence.
Boorman advocates the use of two types of checklists—DO-CONFIRM and READ-DO—and advises us to select the one most suitable for the task. A DO-CONFIRM format allows professionals to perform work from memory and experience and then pause and confirm that the specified tasks/steps were completed and in what sequence. In a READ-DO format, users check off tasks as they perform them (like cooks following a recipe).
According to Boorman, the successful checklist ideally fits on one page, is free of unnecessary color and clutter and uses both upper and lower case in a sans serif font such as Helvetica.
In the maintenance field, we are probably most familiar with the operator checklist written in a DO-CONFIRM style, used as a due-diligence check and commonly performed in a TPM (Total Productive Maintenance) or 5S environment.
Adopting the checklist manifesto
I have found, in my experience as a maintenance management consultant, that work-order instructions—even for planned standardized maintenance tasks—aren’t only wildly inconsistent, they play a huge role in the resulting varying quality of work and mean times to repair. This is due, largely, to the sometimes-conflicting interpretations of job requirements and planning practices these instructions reflect.
As the skilled workforce diminishes, maintenance departments are increasingly tasked to do more with less. Coping successfully with this transition means applying innovative strategies and tools to ensure work is performed consistently and faster. One such strategy already proving that the result is worth the effort is adoption of the checklist manifesto for maintainers and operators—for both planning and work execution purposes. Modeled on successful aviation and medical-industry checklist formats, it can be one of the most powerful tools your organization uses. Good Luck! MT
FYI: Ken will present Industrial Lubrication Fundamentals: Certification Preparatory Workshopa three-day, ICML-related Professional Development Course, at MARTS 2013. For details on this value-added lubrication-training opportunity, visit www.MARTSConference.com.