checklists

When Am I Committed to Collision? A case of art going toward science, but only very slowly.

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According to the author, naval ship handling still relies heavily on craft expertise. His article writes down some formulas and procedures to reduce collision risk.  Source: When Am I Committed to Collision? | U.S. Naval Institute  My own reaction is in a brief comment at the end of the article.

Here is another article in the same issue of US Naval Institute Proceedings that does a great job of explaining how collisions can happen, and why the captain of a USN ship is always responsible, and never completely safe.

This is the burden of command. A captain puts the lives of several hundred sailors into the hands of a young officer, typically 25 years old and typically green. So what does a captain count on to prevent disaster? The captain has “standing orders.” These are the rules in his or her ship that everyone (especially the OOD) lives by. …”

Medicine Grand Rounds at Stanford

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Yesterday I gave a Grand Rounds presentation at Stanford Med School. My title was

Craft, Standardization and Automation: Powerful yet Perilous Paradigms for Control when Lives are at Stake

Most of my talk was about the adoption of procedures (checklists) by US military aviation, during and after WW II. It has close analogies to the situation of health-care today.  Here is my short presentation.  A much longer presentation, with more examples but without discussion of medicine, is here.

Initially, I was concerned that my topic might seem too esoteric for Stanford’s medical faculty. However, their Medical Grand Rounds program covers a lot of ground. My topic was only 1.5 standard deviations away from the mean.

For more of my research on flying paradigms and how technologies evolve from crafts to sciences, please see this page.

 

How flying changed from a craft to a science: Chapter 1 available

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I have just uploaded Chapter 1 of my book manuscript. It summarizes four revolutionary changes in how people flew. It outlines some themes of the full book, including People and Work and Is Science Inevitable?. And of course it includes a few gripping tales of accidents averted – or not.

Commercial aviation today is very safe and scientific. But it wasn’t always. Please send comments, anything from typos to critiques.

Over August I will put up some photographs and key tables from the full book.

Tumblr? Pinterest? What should I use?

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What’s a good place to put supplemental information, especially photos and tables, for my book? I have a lot of old photographs, and putting them into the book itself gets expensive. Some are in color and some are very large. Here are a few examples.
I could set up my own site, or use my publisher’s, but places like Tumblr know how to run photo sites. The ideal features I want include being able to link to pictures on other sites (due to copyright restrictions), able to create tables of contents, etc. Straight chronology won’t suffice.

Obvious candidates

include Tumblr, Pinterest, Instagram. I don’t use any of them except to dabble, so I don’t know their strengths. Possibly Twitter or Facebook?

All advice welcome. Email me, or post comments here.

Are urban hospitals better?

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I was teaching the Virginia Mason VMMC case in Tech & Operations Management yesterday, and made a loose comment about busy urban hospitals being better than suburban ones. For example in the UC San Diego system, when someone is my family is really sick  I try to take them to the downtown (dilapidated, overcrowded) UCSD hospital before I’d go to the one near campus (hotel-like, luxurious).

A student asked “why”, forcing me to do a little research. Here is my answer to her. Continue reading →

How often do pilots skip checklist steps?

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Board blames fatal overrun on pilot error.
Source: NTSB Issues Bedford Gulfstream IV Crash Report | Flying Magazine

Checklists were a major innovation in flying, and are now being pushed in health care. But as I research this, it’s clear that although pilots all swear by them, use is less than 100%. Perhaps less than 99% – and a 1% error rate is very high when there are hundreds of items on a flight.

It’s very hard to know the real number. But the pilots in this crash, both very experienced, did pre-takeoff control checks for less than 10% of their flights!

Data from a recorder installed in the airplane showed that in the previous 176 takeoffs, full flight control checks as called for on the GIV’s checklist were carried out only twice and partial checks only 16 times. The pilots on the evening of the accident skipped the flight control check, which might have revealed to them that the gust lock mechanism was still engaged.

This particular item – forgetting to unlock the “gust locks” – has been killing pilots since the first gust locks. Famous examples in the 1930s were the prototype B-17, and the head of the German Air Force. (Both discussed in my forthcoming chapter on standard procedures in aviation.)
Gulfstream IV jet with six on board - crashed and burned after failed takeoff.

Changing flying from a craft to a science: what went right, and what went wrong, in World War II

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I have just finished  a working paper called  NOT FLYING BY THE BOOK: SLOW ADOPTION OF CHECKLISTS AND PROCEDURES IN WW2 AVIATION. It tells how, in 1937 shortly before World War 2,  the American air forces invented a much better way to train new pilots, and to fly complex aircraft and missions. What they invented is now used all over the world, by all licensed pilots and military aviators. But during the war, even American pilots resisted switching to the new way of flying. The only full-speed adopters were the strategic bombing forces attacking Germany and Japan. The US Navy, despite being one of the 1937 inventors, did not fully make the switch until after 1960!

Precise flying was a matter of life or death.

Precise flying was a matter of life or death.