Industrial infrastructure and processes are increasingly complex and automated. Yet human supervision and control remain a crucial part of industrial operations. Inevitably, we (humans) make mistakes. It’s in our nature. There are many factors at play here: inadequate training is the most common cause of equipment failure ; lack of clear and correct procedures; experienced operators leaving the organization; people relying on memory rather than following checklists; external factors affect our performance e.g. conditions can be noisy with extreme temperatures, stress, fatigue, etc.
The ASM Consortium publishes a regular list of incidents in the process industries globally. Within a 5 day period, 11-16 September 2016, there were 36 incidents causing major shutdowns globally, and 5 people died in 5 days in the US alone. This is not a definitive list, implying that many more accidents may have taken place during this timeframe. And for every accident, there are many near misses that go unnoticed or unreported.
The aviation industry shares similar traits. People are the biggest cause of airplane accidents, accounting for 80% of all accidents. Machine-caused accidents account for the rest. Although this statistic might shock you, the actual accident rate per million flights flown is extremely low (2.8 per million departures). Air travel is extremely safe and reliable, thanks to the fact that aircraft are increasingly very reliable machines and, equally important, that the pilots, crews and mechanics follow checklists regardless of experience and skill level.
Checklists are the key. Pilots rely on them, ever since they were introduced by Boeing and the US Military in 1935. Checklists set the boundaries within which pilots can operate each type of aircraft. Hence a pilot can successfully fly a plane with a co-pilot, with whom they have never flown before. They are able to execute their plans effectively and consistently. Pilots do not rely on memory, especially with the increasingly complexity of aircrafts. Checklists allow pilots to execute numerous tasks quickly and methodically.
Good checklists are precise and easy to use, even in the most difficult situations. A checklist cannot fly a plane, yet they act as reminders of the most critical and important steps – ones that even a highly skilled professional could miss. Good checklist are, above all, practical. And they are the best tool you can use to review, practice and master your job.
Over a quarter of aircraft accidents can be traced back to a maintenance-caused event. Errors and violations could include an innocent mistake (failing to see a crack in a wing), intentionally disregarding company policies, e.g. not using manuals, memorizing checklists, cutting corners due to time pressure or using the incorrect tools to finish a job. Checklists play a key role in minimizing errors and violations in aviation. And they have proven to be successful in the industry.
The medical industry has experienced similar issues. In his book, “The Checklist Manifesto”, Atul Gawande concludes that experts need checklists – literally – written guides that walk them through the key steps in any complex procedure. Gawande helped develop a checklist for surgery, which was trialed in 8 hospitals around the world. Thanks to the introduction of this simple checklist, serious complications following surgery decreased by 37 percent, and deaths from surgery decreased by 47 percent. It was a huge success.
Medical procedures are increasingly complex, and medical professionals need checklists to ensure they execute procedures in the correct order and do not miss anything. In Michigan, United States, an initiative that introduced checklists into the ICU’s (Intensive Care Units) saved $175 million and over 1500 lives in 18 months.
The same is true in the finance industry, where some fund managers use checklists when making investment research and decisions. Fund managers who use such checklists can tackle huge amounts of analytical work and have the confidence that they can rely on the checklist to achieve results.
Industrial operations is similar; procedures and equipment are becoming increasingly complex, and humans continue to play a key role. Checklists have nothing to do with competence or lack thereof. Experts and rookies can both get seduced and cut corners during their shifts. A good decision requires looking at the issue from many viewpoints, and a checklist ensures that you tackle all of them. It frees up your mind, allowing you to really concentrate on the issue at hand.
Envisage the concept of READ – DO – CONFIRM: You read the instruction, do it in real life and then confirm you have done. You have a set of checks to ensure the simple yet critical issues are not overlooked, and you have another set of checks to ensure people communicate, coordinate and accept responsibility while, at the same time, being left to manage the nuances and unpredictable outcomes in the best way they know how.
According to Honeywell, the process industries in the United States lose $20 billion annually, half of which is directly attributable to human error. We expect the actual figure to be higher based on discussions with ARC Advisory Group.
The opportunity is big. Companies could save billions through implementing a culture of checklists. Checklists help ensure goals are achieved, while at the same time, give field operators the freedom to use their own knowledge and intuition.
We believe the process industries should go a step further: moving from written checklists to visual checklists. It is through realistic representations of operating procedures that field operators can quickly understand and master every critical procedure. Visual checklists allow operators to quickly interpret every step without ambiguity, whether on-site while executing the procedure or while training in the classroom.
Companies can save big money and lives through visual checklists: fewer mistakes, improved information retention, increased productivity, faster training cycle, ensuring the simple stuff does not get missed and easing workload on resources. Checklists, supported by realistic visual representations, make life easier for field operators and improve outcomes regardless of skill levels.