How an Effective Checklist System can Reduce the Impact of Human Factors on Equipment Inspections Justin Kerslake Sales an...
Content <ul><li>The Human Element </li></ul><ul><li>The Humble Checklist </li></ul><ul><li>Equipment Inspections </li></ul...
Human Factors <ul><li>Specialty area that is commonly taught in industrial engineering and psychology departments and uses...
Limitations of Human Behaviour? <ul><li>Are errors inevitable? </li></ul><ul><li>Parliamentary Office of Science and Techn...
POST: Elements of System Design       Checklist? Managing information Reducing complexity Constraining behaviour Sta...
The Humble Checklist – Low Tech? <ul><li>Aeronautical </li></ul><ul><li>High risk process </li></ul><ul><ul><li>Nuclear In...
The B-17 - “too much plane for one man to fly” <ul><li>Four checklists were developed </li></ul><ul><ul><li>Takeoff </li><...
The Miracle on the Hudson <ul><li>US Airways Flight 1549 </li></ul><ul><ul><li>double engine failure </li></ul></ul><ul><l...
Surgical Safety Checklist
Safe Surgery Saves Lives <ul><li>“ Medicine today has entered its B-17 phase. Substantial parts of what hospitals (do) ……....
Equipment Inspections <ul><li>The Regulatory Framework: </li></ul><ul><li>H&S at Work </li></ul><ul><li>PUWER </li></ul><u...
HSE:  Key principles in MIT <ul><li>Allocation of roles and responsibilities for managing these activities; </li></ul><ul>...
Objectives of Safe Equipment Management System <ul><li>Identification </li></ul><ul><li>Understood </li></ul><ul><li>Stand...
Good to Go Safety SEMS <ul><li>Three key components: </li></ul><ul><li>a safety checklist book (a carbon copy of the compl...
Good to Go Safety Pod <ul><li>Good to Go Pod conveys instantly if equipment is safe for use </li></ul><ul><li>Status pod i...
Step-by-step use <ul><li>Pod is attached to equipment </li></ul><ul><li>Inspection carried out </li></ul><ul><li>Checklist...
Carrying Out an Inspection <ul><li>When, Who, What </li></ul><ul><li>The checklist - pass/fail </li></ul><ul><li>The “tick...
Checklist Explanation <ul><li>Provides instruction/ procedure </li></ul><ul><li>Removes operative fear </li></ul><ul><li>P...
Management System <ul><li>Top copy placed in the Pod </li></ul><ul><li>NCR copy stays in checklist book </li></ul><ul><li>...
Applications
Benefits <ul><li>Maximises workplace safety  </li></ul><ul><li>Reduces injuries and fatalities </li></ul><ul><li>Complies ...
Benefits over alternatives <ul><li>Seal ensures records cannot be easily tampered with </li></ul><ul><li>Copy of inspectio...
Products <ul><li>Supplied as kits or components </li></ul><ul><li>Available through selected distributors or from dedicate...
Implementation <ul><li>Active employee participation is a positive step towards preventing and controlling hazards.  </li>...
Final Thoughts <ul><li>Humans are fallible and errors are to be expected, even in the best organisations </li></ul><ul><li...
Support Resources www.goodtogosafety.co.uk
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Good To Go Safety Iosh 2010

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Copy of the presentation provided by Good to Go Safety at the IOSH Conference 2010, looking at the history and importance of checklists in the workplace.

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  • Parliamentary office of Science and Technology Managing Human Error Attention - the modern workplace can ‘overload’ human attention with enormous amounts of information, far in excess of that encountered in the natural world. The way in which we learn information can help reduce demands on our attention, but can sometimes create further problems (e.g. the Automatic Warning System on UK trains, see box on page 2). • Perception - in order to interact safely with the world, we must correctly perceive it and the dangers it holds. Work environments often challenge human perception systems and information can be misinterpreted. • Memory - our capacity for remembering things and the methods we impose upon ourselves to access information often put undue pressure on us. Increasing knowledge about a subject or process allows us to retain more information relating to it. • Logical reasoning - failures in reasoning and decision making can have severe implications for complex systems such as chemical plants, and for tasks like maintenance and planning.
  • Crew members close and lock their visors (T-2 minutes, 0 seconds) Orbiter transfers from ground to internal power (T-50 seconds) Ground launch sequencer is go for auto sequence start (T-31 seconds) Activate launch pad sound suppression system (T-16 seconds) Activate main engine hydrogen burnoff system (T-10 seconds) Main engine start (T-6.6 seconds) T-0 Solid rocket booster ignition and liftoff!
  • On October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S. Army Air Corps held a flight competition for airplane manufacturers vying to build its next-generation long-range bomber. It wasn’t supposed to be much of a competition. In early evaluations, the Boeing Corporation’s gleaming aluminum-alloy Model 299 had trounced the designs of Martin and Douglas. Boeing’s plane could carry five times as many bombs as the Army had requested; it could fly faster than previous bombers, and almost twice as far. A Seattle newspaperman who had glimpsed the plane called it the “flying fortress,” and the name stuck. The flight “competition,” according to the military historian Phillip Meilinger, was regarded as a mere formality. The Army planned to order at least sixty-five of the aircraft. A small crowd of Army brass and manufacturing executives watched as the Model 299 test plane taxied onto the runway. It was sleek and impressive, with a hundred-and-three-foot wingspan and four engines jutting out from the wings, rather than the usual two. The plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill. An investigation revealed that nothing mechanical had gone wrong. The crash had been due to “pilot error,” the report said. Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, a retractable landing gear, new wing flaps, electric trim tabs that needed adjustment to maintain control at different airspeeds, and constant-speed propellers whose pitch had to be regulated with hydraulic controls, among other features. While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. The Boeing model was deemed, as a newspaper put it, “too much airplane for one man to fly.” The Army Air Corps declared Douglas’s smaller design the winner. Boeing nearly went bankrupt. Still, the Army purchased a few aircraft from Boeing as test planes, and some insiders remained convinced that the aircraft was flyable. So a group of test pilots got together and considered what to do. They could have required Model 299 pilots to undergo more training. But it was hard to imagine having more experience and expertise than Major Hill, who had been the U.S. Army Air Corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checks for takeoff, flight, landing, and taxiing. 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 this new plane was too complicated to be left to the memory of any pilot, however expert. With the checklist in hand, the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident. The Army ultimately ordered almost thirteen thousand of the aircraft, which it dubbed the B-17. Read more:  http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all#ixzz0iQrSSDD9
  • ATUL GAWANDE NEW YORKER DEC 2007 Orthopaedics and Trauma Volume 23, Issue 5 , October 2009, Pages 377-380 doi:10.1016/j.mporth.2009.08.004  |  How to Cite or Link Using DOI Copyright © 2009 Elsevier Ltd All rights reserved.  Cited By in Scopus (0)   Permissions &amp; Reprints Principles Safer surgery: how a checklist can make orthopaedic surgery safer Mark Emerton a ,  b ,  c , Sukhmeet S. Panesar a ,  b ,  c  and Kirsty Forrest a ,  b ,  c
  • BAS use
  • Good to Go – theme from american military use
  • Good To Go Safety Iosh 2010

    1. 1. How an Effective Checklist System can Reduce the Impact of Human Factors on Equipment Inspections Justin Kerslake Sales and Marketing Director Good to Go Safety/Caledonia Signs
    2. 2. Content <ul><li>The Human Element </li></ul><ul><li>The Humble Checklist </li></ul><ul><li>Equipment Inspections </li></ul><ul><li>A Model Inspection System </li></ul><ul><li>Questions and Resources </li></ul>
    3. 3. Human Factors <ul><li>Specialty area that is commonly taught in industrial engineering and psychology departments and uses a body of knowledge about human characteristics and capabilities and limitations that are relevant to design </li></ul><ul><li>The aim of Human Factors is to optimize the interactions among people, machines, procedures, systems and environments </li></ul><ul><li>Chapanis A. Human Factors in Systems Engineering. Toronto: John Wiley, 1996. </li></ul>
    4. 4. Limitations of Human Behaviour? <ul><li>Are errors inevitable? </li></ul><ul><li>Parliamentary Office of Science and Technology briefing following Cullen Report into Paddington Rail Crash: </li></ul><ul><li>Attention </li></ul><ul><li>Perception </li></ul><ul><li>Memory </li></ul><ul><li>Logical reasoning </li></ul>
    5. 5. POST: Elements of System Design       Checklist? Managing information Reducing complexity Constraining behaviour Standardisation Visibility User centric
    6. 6. The Humble Checklist – Low Tech? <ul><li>Aeronautical </li></ul><ul><li>High risk process </li></ul><ul><ul><li>Nuclear Industry </li></ul></ul><ul><ul><li>Offshore Oil Production </li></ul></ul><ul><ul><li>Healthcare </li></ul></ul><ul><li>Machinery and work equipment inspections </li></ul>
    7. 7. The B-17 - “too much plane for one man to fly” <ul><li>Four checklists were developed </li></ul><ul><ul><li>Takeoff </li></ul></ul><ul><ul><li>Flight </li></ul></ul><ul><ul><li>Before landing </li></ul></ul><ul><ul><li>After landing </li></ul></ul><ul><li>It was simply too complex for any one man’s memory </li></ul><ul><li>These checklists for the pilot and co-pilot made sure that nothing was forgotten </li></ul>
    8. 8. The Miracle on the Hudson <ul><li>US Airways Flight 1549 </li></ul><ul><ul><li>double engine failure </li></ul></ul><ul><li>155 passengers and crew survived </li></ul><ul><li>ECAM  (Electronic Centralized Aircraft Monitoring) electronic checklist </li></ul><ul><ul><li>Engine relight </li></ul></ul><ul><ul><li>Emergency ditching </li></ul></ul>
    9. 9. Surgical Safety Checklist
    10. 10. Safe Surgery Saves Lives <ul><li>“ Medicine today has entered its B-17 phase. Substantial parts of what hospitals (do) ……. are now too complex for clinicians to carry them out reliably from memory alone.”   </li></ul><ul><li>January 2007 the World Health Organization (WHO) began a programme aimed at improving the safety of surgical care globally </li></ul><ul><li>“ Safe Surgery Saves Lives” - introduction of a peri-operative checklist </li></ul><ul><li>In February 2009 the National Patient Safety Agency (NPSA) issued an alert requiring all hospitals in England and Wales to implement the peri-operative checklist by February 2010. The main reason for the checklist is to improve patient care by making the operative environment a safer place </li></ul>
    11. 11. Equipment Inspections <ul><li>The Regulatory Framework: </li></ul><ul><li>H&S at Work </li></ul><ul><li>PUWER </li></ul><ul><li>WAHR </li></ul><ul><li>LOLER </li></ul><ul><li>PASMA </li></ul><ul><li>SEMA </li></ul><ul><li>Et al </li></ul><ul><li>Work equipment should: </li></ul><ul><li>Be regularly inspected </li></ul><ul><li>Be clearly marked as safe for use </li></ul><ul><li>Have auditable inspection records </li></ul>
    12. 12. HSE: Key principles in MIT <ul><li>Allocation of roles and responsibilities for managing these activities; </li></ul><ul><li>A system for identifying relevant plant and equipment - and including it in the MIT system; </li></ul><ul><li>Ensuring that those personnel determining MIT regimes and intervals are competent to do so; </li></ul><ul><li>Provision of appropriate instructions and procedures for MIT staff; </li></ul><ul><li>Ensuring effective communications between all personnel in the MIT system; </li></ul><ul><li>Providing an effective system to record, track and trend key MIT information; </li></ul><ul><li>Procedures for examination, inspection & proof testing have clear pass/fail criteria; </li></ul><ul><li>http://www.hse.gov.uk/humanfactors/topics/testing.htm </li></ul>
    13. 13. Objectives of Safe Equipment Management System <ul><li>Identification </li></ul><ul><li>Understood </li></ul><ul><li>Standardised </li></ul><ul><li>Delegate responsibility </li></ul><ul><li>Record </li></ul><ul><li>Efficient </li></ul><ul><li>Simple </li></ul>
    14. 14. Good to Go Safety SEMS <ul><li>Three key components: </li></ul><ul><li>a safety checklist book (a carbon copy of the completed check is retained in the check book) </li></ul><ul><li>a status pod displays the current status of equipment </li></ul><ul><li>a tamper evident seal guarantees validity of the check list </li></ul>
    15. 15. Good to Go Safety Pod <ul><li>Good to Go Pod conveys instantly if equipment is safe for use </li></ul><ul><li>Status pod is permanently fixed to equipment and identifies it </li></ul><ul><li>Small but highly visible </li></ul><ul><li>Robust, UV stable and water resistant </li></ul><ul><li>Designed to fit flush to scaffolding and other equipment </li></ul><ul><li>Securely contains the completed checklist and incorporates a tamper evident seal to ensure validity </li></ul>
    16. 16. Step-by-step use <ul><li>Pod is attached to equipment </li></ul><ul><li>Inspection carried out </li></ul><ul><li>Checklist completed and dated </li></ul><ul><li>Top copy goes in pod - bottom copy retained in pad, securely in the office </li></ul><ul><li>Equipment safe to use - You’re Good to Go </li></ul><ul><li>Affix seal to ensure record is not tampered with </li></ul>
    17. 17. Carrying Out an Inspection <ul><li>When, Who, What </li></ul><ul><li>The checklist - pass/fail </li></ul><ul><li>The “ticket” </li></ul><ul><li>Communicates status </li></ul>Expiry date
    18. 18. Checklist Explanation <ul><li>Provides instruction/ procedure </li></ul><ul><li>Removes operative fear </li></ul><ul><li>Promotes competency </li></ul><ul><li>Promotes consistency of inspections </li></ul>
    19. 19. Management System <ul><li>Top copy placed in the Pod </li></ul><ul><li>NCR copy stays in checklist book </li></ul><ul><li>Stored in kit box </li></ul><ul><li>Auditable record </li></ul><ul><ul><li>Original handwriting </li></ul></ul><ul><ul><li>Original inspection record </li></ul></ul>
    20. 20. Applications
    21. 21. Benefits <ul><li>Maximises workplace safety </li></ul><ul><li>Reduces injuries and fatalities </li></ul><ul><li>Complies with legislation and industry best practice </li></ul><ul><li>Improves business performance </li></ul><ul><li>Educates staff & improves morale </li></ul><ul><li>Provides indexed audit trail </li></ul><ul><li>Simple to implement </li></ul>
    22. 22. Benefits over alternatives <ul><li>Seal ensures records cannot be easily tampered with </li></ul><ul><li>Copy of inspection can be held securely in office…so even if record tampered with, it can be verified </li></ul><ul><li>Smaller – easier storage, less intrusive on equipment </li></ul><ul><li>Easier to fit with standard cable ties or adhesive </li></ul><ul><li>Same pod suitable for multiple applications </li></ul><ul><li>Standardised system so easy to implement </li></ul>
    23. 23. Products <ul><li>Supplied as kits or components </li></ul><ul><li>Available through selected distributors or from dedicated website </li></ul>
    24. 24. Implementation <ul><li>Active employee participation is a positive step towards preventing and controlling hazards. </li></ul><ul><li>Ownership for safety can be increased by providing effective training, and providing opportunities for employees to be responsible personally for areas of safety. </li></ul><ul><li>• </li></ul><ul><li>http://www.hse.gov.uk/humanfactors/topics/testing.htm </li></ul>
    25. 25. Final Thoughts <ul><li>Humans are fallible and errors are to be expected, even in the best organisations </li></ul><ul><li>Errors should be seen as consequences rather than causes, having their origins not so much in the perversity of human nature as in “upstream” systemic factors </li></ul><ul><li>Countermeasures are based on the assumption that though we cannot change the human condition, we can change the conditions under which humans work </li></ul><ul><li>A central idea is that of system defences - barriers and safeguards </li></ul><ul><li>When an adverse event occurs, the important issue is not who blundered, but how and why the defences failed </li></ul><ul><li>Copyright © 2000, British Medical Journal </li></ul><ul><li>Human error: models and management BMJBMJ. 2000 March 18; 320(7237): 768–770 </li></ul><ul><li>James Reason,  professor of psychology </li></ul>
    26. 26. Support Resources www.goodtogosafety.co.uk

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