I can't believe that I missed that October 30th was National Checklist Day! One of our superb facilities project managers reminded me in his daily e-mail update. Actually, to be 100% honest, I didn't even know there was such a day of recognition until he told me. I've posted at least a couple of times in the past on checklists (see "Aviation checklists - an interesting observation" and "Today, I was a doofus...maybe I should use a checklist?"). They are an important tool utilized by most High Reliability Organizations.
If any of you have ever read the excellent book, The Checklist Manifesto by Atul Gawande, you will at least have read about the significance of October 30th in the history of checklists. On October 30, 1935, Boeing was set to debut the most technologically advanced aircraft ever made, the Model 299 (also known as the B-17 Flying Fortress) at Wright Field in Dayton, Ohio. The large, shiny aircraft raced down the runway in front of an anxious and excited audience. It lifted off the ground, started its climb, and then promptly crashed after making it to just 300 feet. Two of the country's top test pilots (Army Air Corps Major Ployer Peter Hill and Boeing's Leslie Tower) died in the crash. The audience, which consisted of several top military generals, were stunned. A subsequent investigation revealed the cause - the test pilot Major Hill had forgotten to release the gust lock, a device that keeps the rudder, elevators, and ailerons from moving due to excessive wind while the airplane is parked on the ground. Hill had tried to unlock it shortly after take-off, but it was too late.
Importantly, the Army Air Corps wanted to make the Model 299 its principal bomber aircraft. However, the generals came under intense pressure from critics who thought Model 299 was too complex to be flown - there were at least 30 steps that had to be completed in sequence just to make the plane ready to fly! The Army Air Corps had to think of something to change that if the Model 299 was going to ever fly again.
According to Gawande, the Army Air Corps leaders asked their own test pilots for potential solutions ("Deference to Expertise"). The test pilots came up with an incredibly simple yet ingenious solution - a checklist. He writes, "They created a pilot’s checklist. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But flying this new plane was too complicated to be left to the memory of any one person, however expert."
The test pilots' plan called for them to check off each item listed on a piece of paper that included all the major steps to prepared the plane for take-off. Using the checklist would ensure that nothing was overlooked and every step was completed. The new procedure worked great, and it was soon adopted for use on all the rest of the Army Air Corps' airplanes. More importantly, the checklist saved the Model 299, which did, in fact, become the principal bomber used during World War II, primarily in Europe. In fact, the B-17 Flying Fortress dropped more bombs than any other aircraft during World War II.
The checklist has since been adopted as an important safety tool in just about every industry out there. If you want to learn more about the events of October 30, 1935, check out David Kindy's article in the Smithsonian's Air and Space Quarterly, "On. Set. Checked." If you want to read more about how checklists are used in health care, check out either Atul Gawande's book The Checklist Manifesto or Safe Patients, Smart Hospitals by Peter Pronovost. Next year, I will be sure not to forget National Checklist Day!
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