January 6, 2010 | Ken Reed

Root Cause Analysis Tip: Use of Checklists

Yesterday, I posted an article that discussed the advantages of using checklists in the medical profession (see this link).  I thought I’d talk a little more about checklists and how the use of checklists shows up on the Root Cause Tree® Diagram.

Let’s look at a reactive incident, where someone made a mistake while performing a common yet labor-intensive evolution.  For example, a mechanic was starting up an expensive compressor, and he forgot one step, causing serious damage to the machine.  He has done this evolution several times and is familiar with the equipment, but this time, one step out of 16 was missed.  This is a very typical example, and your analysis must take into account many different possibilities.  Happily, TapRooT® walks you through the analysis to make sure you don’t forget to check everything.  The Root Cause Tree® and Dictionary® will have you check many potential problems (fatigue, equipment design, work environment, supervision, etc).  However, I’d like to concentrate on:

“When should we expect to have a checklist in place?”

Looking at the Corrective Action Helper® under no procedure, we get some ideas concerning when a step-by-step checklist makes sense. 

– First of all, if a new checklist had been in place, would performance have improved?  Would this mistake have been prevented?  Sometimes, the task is so obvious that having a checklist would not fix anything.  If this is the case, don’t write a silly checklist just for the sake of having a checklist.  For example, if someone forgets to wear his seatbelt, I highly doubt that putting a checklist in the cab of the truck telling the driver when and how to put on a seatbelt is going to make any difference.  This is an obvious evolution, and other corrective actions (audits of seatbelt compliance, proper rewards for wearing seatbelts, consistent enforcement of the rule) will be much more effective.

Additionally, situations where other factors have made it easy for the operator to make a mistake (poorly designed equipment, excessively fatigued workers, etc.) probably need these other issues addressed first and then evaluate whether a procedure would also help.

– The Corrective Action Helper® also states that a checklist makes sense for high-risk, high-consequence tasks that must be performed correctly every time and require considerable short-term memory.  Starting this expensive compressor is an example where checklist use should be considered.  Other examples include:
a. documentation of the work is required
b. extremely infrequent evolutions
c. tasks that must be performed under stress, like emergencies (both aircraft engines shut down due to a bird strike?)

What do you do when you have checklists, but people aren’t using them?  You are now under the enforcement root cause, and the Corrective Action Helper® has a load of great information on how tackle this problem.

What are your thoughts on checklists?  Do you have examples of checklists that helped?  What about a checklist that was completely useless at your facility?  Let me know what you think!

Root Cause Analysis
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