1. CHECKLIST THEORY Jon Paul Bonofiglio National Superconducting Cyclotron Laboratory Michigan State University 640 S. Shaw Lane East Lansing, MI 48824 1-517-908-7308 bonofigl@nscl.msu.edu Accelerator Reliability Workshop 2013 ORAL PRESENTATION

2. Outline Why Are Checklists Important (2) What Type Of Problems Can Be Addressed By Checklists (2) Types Of Checklists (1) Checklist Development (4) Checklist Communication (1) Checklist Example at NSCL (3) Resistance To Checklists (1) Future (1) Conclusion (1) References (1) Introduction To NSCL, MSU And Cyclotrons (3)

3. NSCL National Superconducting Cyclotron Laboratory (NSCL) is a world leader in rare isotope research and nuclear science education Located on the campus of Michigan State University NSCL employees 519 Faculty, Staff and Students

4. Michigan State University MSU has over 11,000 employees In 2012, MSU enrollment consisted of 48906 students from all 50 United States and 130 countries 21km 2 main campus 70 km 2 throughout Michigan, used for agricultural, animal, and forestry research Located in East Lansing, Michigan

5. Cyclotrons & Beam Lines K500 Cyclotron K1200 Cyclotron Upper Cap Weight = 82 Tons Coupling Line A1900 Fragment Separator

6. Checklists improve outcomes with no increase in skill Improved outcomes in accelerator maintenance means improved availability Improved availability allows a facility to meet its operational goals Why Checklists ? Complexity of systems have increased beyond what humans can manage Fallibility of human memory and attention Humans will skip steps even when they remember them….”This has never been a problem in the past” **A checklist is NOT a teaching tool or an algorithm

7. Why Checklists ?....continued Complexity of systems have increased beyond what humans can manage Boeing 787 Cockpit, 2013 Sopwith Camel, 1917

8. The Study of Complicated and Complex Systems 2002 Study by Glourberman & Zimmerman Simple Complicated Complex Commission on the Future of Health Care in Canada ISBN 0-662-32778-0 Problems can be broken down into 3 distinct categories

9. Simple, Complicated and Complex Simple Complicated Complex In simple problems like cooking by following a recipe, the recipe is essential. It is often tested to assure easy replication without the need for any particular expertise. Recipes produce standardized products and the best recipes give good results every time. Complicated problems, like sending a rocket to the moon, are different. Formulae or recipes are critical and necessary to resolve them but are often not sufficient. High levels of expertise in a variety of fields are necessary for success. Raising a child, on the other hand, is a complex problem……………… Glourberman & Zimmerman: ISBN 0-662-32778-0

10. DO-CONFIRM READ-DO Checklist Types Items are checked-off as they are performed. Baking a cake is an example of a Read-Do checklist Order of operations is critical Items are done from memory Items are confirmed at a “Pause Point” Order of operations is not critical Use natural breaks in work flow “Pause Points”

11. Communication Communication is a key factor in the successful execution of any checklist US Airways Flight 1549 “Miracle on the Hudson” NTSB/AAR-10/03 PB2010-910403 “Contributing to the survivability of the accident was (1) the decision-making of the flight crewmembers and their crew resource management during the accident sequence;” The “Engine Dual Failure” checklists was attempted after the initial bird strike (only 1/3 was completed due to low altitude)

12. Checklist Development Aviation In October 1935, a Boeing 299 (B17) crashed during a demonstration flight for the United States Army Air Corps Pilot error was determined to have caused the accident The pilot neglected (forgot) to release the elevator lock prior to takeoff 4 Checklists were developed in response to the accident Takeoff Flight Landing After Landing Checklist are now routinely used in civil aviation Training was not the issue, this was Boeing’s most experiencedtest pilot

13. Checklist Development ….continued Medical In 2001, a Dr. at Johns Hopkins Hospital tried a checklist to prevent central line infections A 5 step checklist was devised and nurses were asked to observe the Dr.’s while performing the checklists One third of the time, at least one step was skipped In 2004, ~230M major surgeries were performed world wide, resulting in 7 million injuries and over 1 million deaths In 2006, the World Health Organization (WHO) started on a global program to reduce injuries and death A single page checklist “Surgical Safety Checklist” was developed containing 3 phases Before induction of anesthesia Before skin incision Before patient leaves the operating room In the 8 test sites where the checklist was implemented, major complications fell 36% and deaths fell by 47% Extrapolated world wide, this would result in 2.52M fewer injuries and 470K fewer deaths

14. Checklist Development ….continued Building Building construction uses a project plan “construction schedule” which is essentially a checklist The process involves another project plan, which is called a “submittal schedule”, which is also a checklist The submittal schedule specifies communication tasks, the construction schedule specifies building tasks The submittal schedule forces people to communicate at certain points in the construction schedule

15. Checklist for Checklists

16. Checklist Example (before) Included items after the objective was met Clear Objective 52 individual Steps No Natural Pause Points Presented as a Read-Do checklist, but was not performed as such Contained items to be recorded that were never used

17. Checklist Example (after) Items after the objective is met, moved to separate checklist Clear Objective 33 individual Steps Contains Pause Points Hybrid containing both Read-Do and Do-Confirm checklists

18. Checklist Example (after) ….continued Items not in the Cap Raising checklist moved to new checklist Clear Objective 6 individual Steps

19. “My Job is too complicated for a checklist” Resistance to Checklists “I’m giving up control if I use a checklist” “It’s not easy to use” Is it more complicated than major surgery, flying an aircraft, or building a sky scraper? Involve the users in the development of the checklist? Is it easier to fix the mistakes if a checklist is not used and something goes wrong? Participants where the Surgical Safety Checklist was used were surveyed: 80% said the checklist was easy to use, didn’t take a long time to complete and had improved safety 78% observed the checklist to have prevented an error Still, 20% did not find it easy to use, took to long and felt it had not improved safety. When participants were asked “If you were to have an operation, would you want a check list to be used?” 93% said YES

20. Future Review other checklist at NSCL to see what improvements can be made Explore the use of tablets for implementation of checklists Additional checklists needed for Abnormal Situations

21. Conclusion Checklists improve outcomes with no increase in skill Communication is a key factor in the successful execution of any checklist Involve the users in the development of the checklist? A checklist is NOT a teaching tool or an algorithm Checklist must have clearly stated objectives? Decide what type of checklist works best: Read-Do, Do-Confirm or Hybrid

22. References The Checklist Manifesto, Atul Gawande, ISBN-10: 0312430000 Basic principles of checklists, http://www.basicsm.com/node/2 http://www.basicsm.com/node/2 How Checklists Make You Smarter – The Works http://www.chrisbrogan.com/how-checklists-make-you-smarter-the-works/ http://www.chrisbrogan.com/how-checklists-make-you-smarter-the-works/ Safety Culture Communicator http://pbadupws.nrc.gov/docs/ML1122/ML11228A218.pdf http://pbadupws.nrc.gov/docs/ML1122/ML11228A218.pdf Cockpit Checklists: Concepts, Design and Use http://ti.arc.nasa.gov/m/profile/adegani/Cockpit%20Checklists.pdf http://ti.arc.nasa.gov/m/profile/adegani/Cockpit%20Checklists.pdf Checklists are the Key to Preventative Maintenance http://www.distributionteam.com/files/PM%20Checklists.pdf http://www.distributionteam.com/files/PM%20Checklists.pdf Accident Report NTSB/AAR-10/03 PB2010-910403 http://www.ntsb.gov/doclib/reports/2010/aar1003.pdf http://www.ntsb.gov/doclib/reports/2010/aar1003.pdf