Re: CRM and Checklists
Reid Fairburn (cr_king_at_cr_king.seanet.com)
Fri, 4 Oct 1996 18:14:02 -0700 (PDT)
At 09:42 AM 10/4/96 -0400, you wrote:
>In a message dated 96-10-03 16:56:15 EDT, you write:
>
><< I agree that checklist design and use are critical. Accident reports
>abound
> with examples of either poor checklist construction or discipline resulting
> in tragedy. But CRM, unlike the checklist, is not just for a specific
> situation. CRM is an all-the-time set of behaviors--- a part of an overall
> culture of aircrew attitude and performance. Whereas checklists play an
> important, even critical, part in those behaviors, it is still only a part.
> >>
>
>BUT there's a danger in looking for the "ingredients" of incidents and
>accidents. In an earlier message I admitted to being an interloper from
>another world (human performance in nuclear power), where Jim Reason & I
>looked at 21 abnormal events that involved a significant element of human
>performance--roughly half where performance was astonishingly good and half
>where it was astonishingly bad (I forget now which was 10 events and which
>11, but you get the point, I hope). Even in the events where people did
>really well, bad procedures were a factor in the scenario at least 50% of the
>time--in other words the operators did brilliantly despite lousy procedures.
> Poor procedures do not discriminate good and bad human performance; it only
>looks that way if you only look at "bad" performance events.
>
>--Like the poor, bad procedures are always with us. Our work suggests a
>variety of reasons, one being that the "operating envelope" is broader than
>the mind of the procedure writer imagines.
>
>Well, just a passing comment from an outsider.
>
>Any different in your business?
>
=====Unfortunately, I think that things are similar here but there is a
glimmer of improvement as the years go by. One thing that just really
irritates me is the reluctance of manufacturers to address really sticky
abnormals, where judgement is required, with any suggested guidance. The
reason being in most cases, that the company lawyers don't want the
liability of helping someone make the decision. Our manufacturers have to
step up to the task of providing sound guidance in tough abnormal situations.
Reid Fairburn
Creative Kingdom, Inc.
cr_king_at_cr_king.seanet.com
206-946-4815