In the last thirty years, aviation has had a radical cultural transformation. The transformation has been a critical shift in an industry where safety is the number one priority. Using checklists has made all the difference in this industry and aircraft accidents have been on a steady decline since the 1980’s, when checklists were developed for flight crews.
Little mistakes in aviation compound into huge problems. In commercial airlines, pilots are often meeting for the first time and are expected to solve complex problems with virtual strangers. Aviation safety was improved through more than just implementing checklists, as important as they are. Checklists alone cannot make a workplace safe. In the aviation industry, unavoidable human error was rejected long ago, replacing this mind-set with a strong safety culture and a reliance on proven procedures.
Pilots turn to checklists
When issues arise mid-flight it can be a natural response to troubleshoot and rely on one’s judgement. Pilots turn to checklists for two reasons. One, they are trained to do so instead of relying on memory, and two, checklists have proven time and time again that they work. Pilots have learnt to trust the checklist procedure, even when faced with the catastrophe, it is the checklist they choose. Read more about how to make an effective checklist here.
Lessons from Checklist Manifesto
The best seller by Atul Gawande advocates for using checklists as teams in our professional lives. The use of checklists dramatically raises effectiveness and reduces errors. This is true even when experts are in charge. The book notes that in our complex age, no one person can remember all the essential steps to perform a complex procedure. Checklists provide a cognitive net, catching all the mental flaws that are inherent to us.
Within the book, Gawande describes how Boeing issues over one hundred meticulously put together checklists each year.
A Checklist Manifesto notes that bad checklists are vague, imprecise and impractical, spelling out every single step. Good checklists, on the other hand, are precise. They are are efficient, to the point, and easy to use in the most difficult situations. Gawande notes that checklists alone cannot fly a plane, but they can make priorities clearer and prompt people to function better as a team.
Gawande’s research explains that experts often oppose the idea of reducing their complex jobs to a simple checklist. Surgeons in particular frequently think that relying on their own expertise or hard-earned knowledge is the only way to successfully do their job. However, pilots could decide to try harder not to crash their plane, or dismiss previous crashes as a result of inexperience. Instead, successful pilots accept they are human and therefore prone to human error, and choose a checklist as their primary tool.
Gawunde interviews Daniel Boorman of Boeing, a veteran pilot who spent two decades developing checklists and flight deck controls. He has studied thousands of aviation crashes and near crashes, developing the science of avoiding human error. They break checklists out into “normal” everyday actions, this would include a pre-flight checklist, but also into “non-normal” checklists covering emergency situations. Following are some of the guidelines established by Dan Boorman, the checklist expert at Boeing, and tips that you can apply to your own checklists:
Define clear pause points
Pause points determine when a checklist should be used – when starting a new task, for example
Determine whether your checklist is a Do-confirm vs. Read-do checklist
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.
Keep a checklist between 5 and 9 items
Boorman stresses that this is not an absolute rule but humans’ working memory is generally between 5-9 items. In some situations you may have more time to perform a task and so can expand the checklist. If the list is too long, you risk having people shortcut some of the items.
Focus on “killer items”
These are the items in the checklist that are the most crucial but also frequently overlooked. This is why testing checklists and gathering data is so important, so you can identify where these “killer items” are.
Wording should be simple and precise
Use occupation-specific language, terms the reader will be very familiar with
Fit the checklist on one page, and keep it free of unnecessary clutter
Most importantly, test your checklist
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.
Changing definitions of authority
Before the introduction of a Crew Management System (CMS) in the 1980’s, a series of crashes took place that could have been avoided. Error was once viewed as a weakness and people looked to blame as a result. Now in the cockpit, errors are dealt with immediately and turned into learning exercises where the team can evaluate them and manage them better next time.
With the CMS, the roles were redefined. The captain focused more on managing the team and their efficiency than the individual tasks he needed to complete. The role of the copilot and team members were to not blindly obey orders, but to monitor issues and have a voice in decision making.
The transformation has made aviation safer due to shifting the definitions of authority. It is said that the captain was ‘king’ and his subordinates were not to question his methods, but now the culture ingrained is to call out any mistakes regardless of rank. The result is fewer airplane crashes and better working relationships. A simple concept that can be applied to your own company to ensure each employee is accountable.
Instead of focusing on hierarchy, the industry puts emphasis on individual intelligence to foster team intelligence. In the old days, young pilots would be too scared to point out errors from their high-ranking officials, causing many critical errors to slide through.
Possessing emotional intelligence is seen as a vital skill when it comes to working in teams. While it is an important concept, creating genuine teamwork requires moving beyond the focus on our own individual emotional intelligence, to that of ‘team intelligence.’ A Cornell research paper states that emotional intelligence on its own is not enough. Team intelligence goes a little deeper, where individual members of a team must learn, teach, communicate and think together, regardless of their authority.
In the case of the 2009 US Airways Flight 1549, the crew managed to safely evacuate 154 passengers in minutes, due to effective teamwork and checklist procedures put in place.
Another important aspect of teamwork within the aviation industry, is reporting all errors. In doing so, critical data for investigations can be used to make vital improvements to safety. The aviation industry routinely interrogates errors to avoid the same occurrence in the future. Where there is a significant blame culture, human error will continue to take place.
Change doesn’t happen overnight
Air accidents peaked in the 1940’s, but have been on a steady decline since the 1980’s.
The desire to develop a transformation in the industry didn’t occur overnight. Stakeholders were called in to refine and improve the current system, including unions, researchers, company officials, government officials and academics over a few years and many workshops. The aviation safety curriculum was supported by decades of research and ongoing reform. The decrease seen in aviation accidents provides a strong incentive to continue to use checklists.
Applying these lessons to your own business
Avoidable failures are everywhere, particularly in high-risk industries. The volume and complexity of what we know today has exceeded our ability to deliver many procedures safely. The key takeaway we can learn from aviation is that a follow-up plan, regular briefings, teamwork procedures and ongoing communication has been the game changer for the aviation industry. And they have proved time and time again, that having an emphasis on team intelligence and effective procedures like checklists can ensuring teams are on the same page and operating at their best.
Find out more about how to create a great aviation checklist here.
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