Wednesday, 14 October 2015

Great NASA story on checklists

The NASA CKO office publishes a series of "learning from experience" stories on their blog called "my best mistake".  This is a great way to spread the concept that mistakes make great learning opportunities.

Photo from wikipedia
I really like this story from David Oberhettinger

It's not so much a "mistake" story as a "value of learning" story. David tells how we was in a small plane preparing for landing when..............

Suddenly, dense black smoke begins to fill the cockpit. I flip the checklist over and follow the five steps listed on the back under In-Flight Electrical Fire:
  • (1) Master Switch to Off
  • (2) Other Switches (Except Ignition) to Off
  • (3) Close Vents/Cabin Air
  • (4) Extinguish Fire (in this case, I isolated a faulty transponder)
  • (5) Ventilate Cabin
These steps took maybe 90 seconds. Then we descended to an uneventful landing. The crisis hardly caused a significant increase in heart rate, because I just followed the checklist.

I have written before about how checklists are a fantastic way to provide knowledge to the decision maker at the point of need, and there can be no more graphic indication of the "point of need" that a smoke-filled cockpit of a small aeroplane.

However David then goes on to talk about how that checklist ended up in his hand.

  • The formal checklist as a concept derives from a lesson that was learned on October 30, 1935, during a test flight of the B17 bomber prototype. The pilots attempted to take off with the tail wheel locked; this prevented the wheel from swiveling and resulted in a crash and the death of both pilots. From then on, Boeing provided a printed checklist with each production version B17. (Previously, pilots were expected to make their own checklists.) 
  • Today, all airplane manufacturers provide a pilot’s handbook containing checklists specific to the model of plane

Therefore, when you buy the plane, you buy the knowledge of what to do in any form of emergency.  This is an excellent example of a "knowledge supply chain", which had become standard practice in the aviation sector because of the life-saving value of the knowledge.

As David concludes
Why do I love checklists? Because a checklist helped avert what could have been some serious unpleasantness. And because rather than letting my imagination run amok to my detriment (otherwise known as “panicking”), effective use of checklists allow me to direct my imagination to more productive purposes.

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