By Steve Kane
I’ve been an aviation enthusiast most of my life. I started flying sailplanes a couple of years ago and recently transitioned to power planes. The first lesson in flying is an introduction to standard work—specifically, the preflight checklist. Like many forms of standard work, the preflight checklist came about as a countermeasure to a problem.
Boeing was competing for a military contract in 1935. The aircraft they were developing was much more complex than any other until that time. A crash occurred during testing. It was determined that the crash was the result of the pilot forgetting to adjust an important setting.
According to John Schamel of www.atchistory.org, this accident put the future of the project and the company at risk. Aircraft and aviation systems, until that time, were simple enough for a single pilot to understand and memorize. The B-17 introduced complexity that proved to be too much to operate safely from memory. Good training and experience were not enough. A countermeasure to ensure the accident would not be repeated needed to be implemented. The project team developed a checklist to make sure all necessary settings were correct and nothing was forgotten.
An Air Force veteran once told me that reading through a checklist and looking to verify conditions or settings were correct was insufficient to meet standards. Air Force flight crew members were required to actually touch the item being checked. The act of touching the item was a way of verifying the crew member actually looked at it and the setting was correct. After all, it’s pretty easy to get in a hurry, rush through a procedure and overlook or forget something.
This came to mind for me during a recent flight in a single engine airplane. I noticed my fuel/air mixture was set to maximum rich. The airplane was performing well, but the mixture should have been set to lean for that portion of my flight. The obvious countermeasure was to pull back on the mixture lever to the correct position, which I did.
The only practical problem with the maximum rich mixture was that I was burning more fuel than necessary. A greater problem was that an important process hadn’t followed correctly. If the mixture was incorrect, what else could be incorrect?
I did some quick root cause analysis mid-flight. A five-why exercise reminded me I had been distracted by air traffic and radio communication earlier in the flight and rushed through a checklist from memory. This led me to conclude that had I followed my standard work correctly, and not from memory, the incorrect mixture setting wouldn’t have happened.
Using the Countermeasure Correctly
I pulled out my checklists and immediately went through each item following the Air Force method. The checklists allowed me to verify all settings were in fact correct and that I could safely continue flying.
Flying, like just about any activity in business or industry, is a process. There are specific inputs that generate specific outputs. Complexity in processes opens the door for variation in results. We get consistent results when we control variation. Standard work serves to do just this.
The thing about standard work is that it is only effective if it is used (actually read) as intended. Written instructions are effective for training and setting standards. Standard work serves to sustain a standard or prevent errors. Essentially, it helps us generate intended results by preventing us from straying from an established process.
In Schamel’s example, the use of standard work (a simple Lean tool) helped keep a company and critical project alive. It also helped protect the safety of countless people over the past several decades.
Here are some elements of effective checklist style standard work:
Complements instructions and training
Quick reference tool
Vertical and visual if possible—posted at the workplace or at least within reach of the person doing the work
Used while the work is being done (while flying)
Follows a sequence
Used regardless of expertise
Standard work reinforces the idea that the work being done is part of a defined process.