What pilot checklists can teach us about KM

This blog often refers to aviation and their use of checklists as a great example of KM operating ata cultural level in an industrial sector. Here are some more thoughts. 

B17 checklist linked from here

• Boeing first turned to checklists in order to recover from a commercial near-disaster.

This document called “How the pilot’s checklist came about” tells us how, in 1934, the Boeing 299 was the frontrunner in an order by the US Army for up to 200 aircraft, and was in the final stages of evaluation in a fly-off against its 2 rivals. It needed to perform well – this order could save Boeing as a company.

Unfortunately the 299 stalled on take-off, crashed and exploded, killing 2 of the 4 crew. The article tells us

“The investigation found “Pilot Error” as the main cause of the accident. Hill, (the pilot, flying the plane for the first time) unfamiliar with the aircraft, had neglected to release the elevator lock prior to take off. Once airborne, Tower (Boeing chief test pilot, also in the cockpit) evidently realized what was happening and tried to reach the lock handle but by that time it was too late”.

The plane was dubbed “too much for one man to fly” and Boeing lost the order. However they managed to persuade the Army to order 13 planes for further testing, and at the same time the Boeing pilots put their heads together to work out how they could avoid future disasters. They realised that the Model 299 was not too much airplane for one person to fly, it was simply too complex for any one pilot’s memory in the heat of the moment.

“In the end, four checklists were developed – takeoff, flight, before landing, and after landing.  These checklists for both the pilot and the co-pilot made sure that nothing was forgotten. With these new checklists, careful planning and rigorous training, the twelve aircraft managed to fly 1.8 million miles without a serious accident. The U.S. Army accepted the Model 299, and eventually ordered 12,731 of the aircraft. This was then numbered the B-17. The B-17 went on to become the most widely used aircraft in WWII”. 

The use of checklists therefore helped rescue Boeing.

• There is more than one way to use a checklist

We can read more about pilot checklists in this great blog post from SafetyCulture entitled “Lessons We Can Learn From Aviation Checklists”. For example there are two ways to read a checklist – Do-Confirm, or Read-Do

“Do-confirm is generally used when team members are experienced and have gone through the necessary steps within the checklist and simply run through it to ensure they’ve been done. With a Read-do checklist, team members perform the tasks as they’re reading through the checklist, similar to a recipe”

Also they suggest that checklists should be linked to identified pause points, should be between 5 and 9 items, on no more than one page, and written in simple language. They also suggest that the process of testing a checklist in practice generates buy-in among the users.

“Testing the checklist ensures you’ve identified all the right pause points, kept it short enough, and that it is easy to understand. The aim of implementing checklists is not simply to have people read through it and check off items. The aim is to incite a cultural change by enhancing teamwork, increasing communication and changing the definitions of authority within a team. The aviation industry has seen clear safety improvements by implementing checklists into their everyday processes, but they also experienced a cultural shift that changed the way teams work together. Checklists have redistributed the responsibility of safety amongst team members by successfully leveraging the team’s collective knowledge”.

Finally the post makes the point that changing the culture takes time, and that aviation safety only really began to improve from the 1980s onwards – 40 years after the first checklist was introduced.

• The concept of checklists does not always translate to other industries

As this blog post, entitled Checklists don’t work* (*sometimes, particularly if you get implementation wrong), points out, translating the concept of checklists from one industry to another is not simple. It describes how early successes with checklists in the medical sector have not been widely adopted, and suggests that the failure was all in the implementation, as follows:

• Staff resisted, or failed to complete the checklist
• The checklist was dismissed as “illogical or inappropriate”.  
• It was just another ‘initiative’ dropped on front line staff by Managers and Administrators. It felt ‘Imposed’.
• It didn’t fit the local context. 

To these reasons you could add the factor of the immediacy and visibility of results in the medical sector (as discussed in my post “why don’t good ideas spread better“), and also perhaps the fact that in the event of disaster, a doctor does not “go down with the plane” like a pilot does, so the level of personal involvement is not the same as it would be for a B37 pilot, for example.

This Nature article suggests that one part of the solution for improving adoption is to allow hospitals to “localise” their checklists, and another is to observe and coach their introduction.

Experts recommend that hospitals modify standard checklists to help the tool fit into the local workflow and to produce a feeling of investment and ownership. Pronovost (anaesthesiologist, critical-care physician and checklist pioneer) encouraged the ICUs that participated in the Keystone project to make his checklist their own. “They were 95% the same, but that 5% made it work for them,” he says. “Every one of these hospitals thought that theirs was the best.”  

(Also) Providing the hospitals with regular feedback on their infection rates created social pressure for improvement, they say, and regular in-person workshops allowed staff from different hospitals to share their experiences and created the sense of a shared mission.