1. Dr. L. Daniel Maxim, Chair NBSAC
Checklists and SOPs
Dr. L. Daniel Maxim, Chair NBSAC

2. Outline of presentation
Introduction: what are checklists and standard operating procedures (SOPs) and why are they valuable?
Warning: avoid normalization of deviance
More about checklists: (history, types, how to write a good checklist, etc.) and boating checklists
Summary and Q&As

3. Members of the Checklist Hall of Fame
Daniel
Boorman
Atul
Gawande
Andrew
Hopkins
Mike
Mullane
James
Reason
Diane
Vaughan

4. introduction

5. Human error: a major cause of accidents/fatalities
Studies in numerous fields confirm the importance of human error as a cause or contributing factor of accidents and fatalities
Therefore, it is important to find ways to manage (avoid, trap, or mitigate) these errors
Standard operating procedures (SOPs) and checklists have proven valuable to reduce human errors

6. Boating Safety Courses
Although boating safety courses offer much useful material on boating safety topics, there is limited discussion of human error and means of reducing human error in recreational boating
This presentation covers proven tools to reduce human error in many fields

7. What is a standard operating procedure (SOP)?
An established procedure to be followed in carrying out a given operation or in a given situation
SOPs may also include checklists as job aids, together with requirements to use various checklists, but SOPs are typically more detailed and ‘less portable’

8. Typical SOP content What is the objective of SOP? (purpose)
What are applicability and use of SOP? (scope)
Who will perform tasks? (responsibility)
Who will ensure implementation of procedure? (accountability)
How tasks will be performed? (procedures, use of job aids)
Who ‘owns’ the SOP and how/when it is reviewed or revised

9. Scope of SOPs in vessels or aircraft
Should include:
Procedures for pre-startup, startup, underway, and shutdown
Procedures for maintenance
Procedures for abnormal conditions and emergencies
Reference to job aids (e.g., forms, templates, flowcharts, checklists)
Contact information where help is available
Training on SOPs should include both normal and emergency drills

10. Difference between an abnormal condition and an emergency
An emergency situation is one in which the safety of the vessel or of persons on board is endangered for any reason
An abnormal situation is one in which it is no longer possible to continue the voyage as planned using normal procedures but the safety of the vessel or persons on board is not in danger
Some overlap between these states

11. Benefits of SOPs
Increase consistency with which tasks are performed (and compliance in cases where regulations involved)
Decrease error (particularly omission and sequence) rates
Define roles and responsibilities (hence increase accountability)
Well thought out procedure can employ ‘best practices’ (at least for the circumstances envisioned by SOP writers)

12. Benefits of SOPs
Facilitate communication (and possible need for retraining) if (when) SOPs are changed, but system must ensure prompt notification of SOP changes (management of change, [MOC])
Well written SOPs reduce training time

13. Difficulties with SOPs
May lead to ‘necessary violations’ if tasks cannot be accomplished using SOPs
May not envision all circumstances
May not be understandable
May be seen as burdensome and unwieldy, encouraging use of informal work procedures (short cuts)
Therefore, SOPs need to be carefully written, updated, and their use monitored

14. ‘Informal work procedures’
‘Work-arounds’ devised by on-scene personnel to meet task demands
Not necessarily bad, because on scene personnel may have intimate knowledge of work demands—however, ad hoc procedures need to be reviewed and approved by competent personnel
Important distinction between ‘work as imagined’ and ‘work as actually done’

15. ‘Informal work procedures’
Informal work procedures may have clear benefits and, if so, need to be incorporated into revised SOPs
But informal work procedures have also been a cause or contributing factor of many accidents (e.g., Esso Longford gas plant, Chernobyl)
For more on this see For more on the Esso Longford case, get the book available at and See also HSE explanation at

16. The way things were!
checklists

17. What is a checklist?
A checklist is a type of job aid used to reduce failure by compensating for potential limits of human memory and attention
It helps to ensure consistency and completeness in carrying out a succession of tasks
The checklist to the right is for a particular model helicopter

18. SOPs and checklists
Typically, an SOP is a larger and more complete document that may specify the use of one or more checklists for various operations or under various conditions
The checklist is an abbreviated memory aid used to ensure and verify compliance with elements of an SOP

19. Why is a checklist valuable?
Checklists help to ensure that tasks or observations are not omitted, done in the correct sequence, and that SOPs are followed
Checklists reduce task saturation and contribute to situational awareness
Use of a systematic procedure has a calming effect in an emergency situation
Use of checklists has proven to be valuable in several fields—originally aviation
The point about reducing task saturation is made in several sources, including, For other discussions see:
Hilton, G., Daniels, K., Goldhaber-Fiebert, S.N., Lipman, S., Carvalho, B. and Butwick, A., Checklists and multidisciplinary team performance during simulated obstetric hemorrhage. International journal of obstetric anesthesia, 25, pp and Müller, S. and Patel, H.R., Lessons learned from the aviation industry: surgical checklists. In Simulation Training in Laparoscopy and Robotic Surgery (pp. 1-6). Springer London and Edozien, L.C., Situational awareness and its application in the delivery suite. Obstetrics & Gynecology, 125(1), pp and Doherty, P.J., Electronic Checklists on Multi-Purpose Displays: A Better Way For Fighter Pilots to Manage Information and Situational Awareness during Periods of High Workload. ARMY COMMAND AND GENERAL STAFF COLL FORT LEAVENWORTH KS SCHOOL OF ADVANCED MILITARY STUDIES.
Some dispute this, arguing that checklists can contribute to task saturation, see Tice, P., The Farce of Pain Scales. Emergency Medicine News, 31(11), pp
An interesting article on checklists and situational awareness can be found at Mullan, P.C., Macias, C.G., Hsu, D., Alam, S. and Patel, B., A novel briefing checklist at Shift Handoff in an Emergency Department improves situational awareness and safety event identification. Pediatric emergency care, 31(4), pp

20. More on medical error
Major study prepared by the National Academy of Sciences
“When extrapolated to the over 33.6 million admissions to U.S. hospitals in 1997, the results of these … studies imply that at least 44,000 and perhaps as many as 98,000 Americans die in hospitals each year as a result of medical errors.”
See Donaldson, M.S., Corrigan, J.M. and Kohn, L.T. eds., To err is human: building a safer health system (Vol. 6). National Academies Press, available electronically at

21. More on medical error
Makary and Daniel (2016) conclude that the human cost of medical error is much greater than calculated in To err is human, possibly as high as 400,000 deaths per year
This is a problem worth our attention
See Makary, M.A. and Daniel, M., Medical error-the third leading cause of death in the US. BMJ: British Medical Journal (Online), 353..

23. Use of surgical safety checklist
Experiments reported by Gawande indicated that the use of the surgical checklist reduced the rate of major complications for surgical patients by 36% and deaths by 47%!
Subsequent studies reported less dramatic, but still worthwhile results
Not all studies have had such success, see e.g., or or

24. Fields where checklists have proven valuable
Aviation
Medicine
Fire and EMS
Nuclear power plants
Chemical plants
Commercial shipping
Finance
Software development

25. More about checklists

26. History of the checklist
Boeing model 299, complex airplane
Oct aircraft crashed after takeoff because elevator lock not released—potential disaster for Boeing Co.
Led to development of checklist and much safer flight
Model 299 became B-17, major bomber of WWII
Numerous sources for this story see e.g.,

27. Types of checklists Procedural checklists Ratings checklists
‘Completeness checklists’
‘To do’ lists
Our focus is on operational or procedural checklists
Checklists may be oral (GUMPS), written, or both
Checklists may be used by an individual or a team
GUMPS is an oral before landing checklist used by aviators of piston engine planes. It stands for Gasoline (fuel on tank with greatest amount of fuel), undercarriage (gear down), mixture (rich), propellers (flat pitch), and switch (electrical fuel pumps on).

28. Writing a good checklist
Not as easy as it sounds
Need to know the task(s)
Need to know the user
Typically done in an iterative way—design, test, refine; periodic updates may be necessary
Need to be complete, but need to be short—conflicting objectives solved by segmented checklists
Typically checklists differ for ‘normal’ and ‘emergency’ events

29. Two concepts for design/use
CDV (challenge-do-verify) also termed challenge-response method:
Using CDV a team member makes a challenge before an action is initiated, then the action is taken and verified
This is most effective if one team member issues the challenge and a second team member takes the actions and responds to the first team member, who monitors the action and verifies that the correct action was taken
See FAA Human Performance considerations in the use and design of aircraft checklists (1995), available electronically at

30. Two concepts for design/use
DV (do-verify) method:
The DV method consists of the checklist being accomplished in a variable sequence without a preliminary challenge. After all the items of the checklist have been completed, the checklist is then read again while each item is verified
Each team member can work independently which helps balance the workload among team members
See FAA Human Performance considerations in the use and design of aircraft checklists (1995), available electronically at

31. Need to know the tasks
Task decomposition—divide the overall task into sequence of relevant subtasks
Request specific task outcomes—not ‘blood pressure checked’ or ‘altimeter checked’ but ‘blood pressure 120 over 80’ or ‘altimeter set to field elevation’
Some tasks must be sequenced in a specified order (e.g., hydraulic pumps must be started prior to checking hydraulic pressure)

32. Need to know the tasks
Some tasks do not have a required sequence or coupling with prior activities and may be selected for other purposes
For example, in an airplane cockpit the gauges, units, and systems panels are arranged in a certain ‘geographical’ location according to frequency of use, criticality etc.
Checklists for these items can be conducted in a particular sequence of motor and eye movements; this is called the cockpit’s ‘flow-pattern’
For more information on this topic see See also

33. Additional pointers
Keep the checklist short (five to nine items) on one page if possible (segment if many more steps required)
Incorporate ‘killer items’ or all steps that are most dangerous to skip and are sometimes overlooked
Use simple, exact wording and language that is familiar to team members

34. Additional pointers
Ensure the checklist is easy to read (typeface, colors, and positioning) and stowed where it is readily accessible
Test the checklist in real world environment; waterproof the checklist if necessary
Where possible, ensure that checklists are designed or reviewed by subject matter experts (SMEs)

35. A family of checklists

36. Need to know the users
Identify conflicting physical demands in the task
Include pauses in checklist for review
Identify who is responsible for completing the task and who responsible for recording the task or response
May need to create checklist for novices—why?
Example of conflicting demands, if hand hygiene is necessary a health care worker cannot be prompted to touch the checklist, wash hands, and re-contaminate his or her hands as he/she records the item on the checklist.

37. Checklist technology

38. Errors in using checklists
Failure to use the checklist
Overlooking item(s) on the checklist
Failure to verify settings or actions visually
Interruption of checklist by external sources
Error(s) or omissions in checklist

39. Why don’t people use checklists?
“We already know what to do;” individualism
Lists are too simplistic/obvious
Lists won’t make much difference
We have done this many times before; complacency
Checklists take too much time; time pressures
No sense of ‘ownership’ of checklists
These and other issues discussed in article by Patricia Ross, available at See also ‘use this checklist or people die’ at See also ‘pilots use checklists, doctors don’t, why not? at

40. Pointers on using checklists
Checklist should be initiated by a designated person (e.g., Captain, Coxswain, Surgeon, Nurse, etc.)
Checklist should be initiated during times of low workload if possible
Use of checklist should be called for following specific cues or events (e.g., ‘before starting engine,’ ‘before fueling’)
These and other issues discussed in article by Patricia Ross, available at See also FAA Human Performance considerations in the use and design of aircraft checklists (1995), available electronically at

41. Cued boating checklist: normal procedures
Normal checklists
Before engine start
Before getting underway
Before docking
Before and after refueling
When securing after use
Here are some interesting references and There are numerous other sources for boating checklists, see e.g.,
also

42. Always use a float plan
Several organizations publish templates for float plans
Pick one that you like and make it a point to fill one out, even for short voyages
USPA Float plan available at
USCGAUX plan available at
Boat-ed plan available at
BOAT/US plan available at
Nautical know how plan at
Coastal Boating net plan available at

43. Emergency Checklists Approaching bad weather Man overboard
Medical emergency, including skipper incapacitation
Restrictive and disabling casualties (MELs)
Taking on water
Low oil or gear oil pressure
High water temperature
Alternator generator failure
Steering casualty
Grounding
Fire
What would you add?

44. Operator’s Manual
An Operator’s Manual is a good source of information in developing checklists
Published Operator’s Manuals for other related craft might be suitable as a starting point
The Coast Guard has Operating Manuals for each of its craft that can give you some ideas. Here is the web site address for the 47 MLB

45. Inspection and repair checklists
Checklists also proven valuable for inspection and repair—your boat’s manufacturer might be a useful source
Other useful sources include marine electronics or engine manufacturer’s operation manuals
For an interesting example of a well illustrated document on this topic, see

46. Pointers on using checklists
Timing of tasks—the ‘window of opportunity’ is the time period in which a tasks can take place
Although a given task can be effectively accomplished at any time during the window, research (FAA) shows benefits of completing checklist tasks early
See FAA Human Performance considerations in the use and design of aircraft checklists (1995), available electronically at

47. Pointers on using checklists
Standard checklist nomenclature should be used exclusively by all persons
When a checklist is interrupted for any reason, the checklist should be stopped by the designated responder as in ‘stop it at flaps set 20 degrees’ this is referred to as an explicit hold; studies show that this lowers likelihood of losing your place
See previous slide for sources.

48. Pointers on using checklists
In the event of an interruption, do not stow checklist until all items in the flow are complete
If there is doubt as to where a checklist was interrupted, chance of error is reduced if the crew returns to the beginning of the task list
When complete, the challenging crewmember should announce ‘checklist complete’ to allow personnel to move on to other tasks

49. ‘Short cutting’ the checklist (results of one study of aviators)
Several pilots deviated from the challenge-and-response method to a faster technique
This technique was to call several challenge items together in one ‘chunk,’ while the other pilot would reply with a series of chunked responses
This technique undermines the concept behind the step-by-step challenge-and-response procedure
For more information on this topic see See also

50. Studies

51. Consequences of failure to use checklists
20 Aug 2008: MD-82 on takeoff from Madrid, flaps not in takeoff position
19 Feb 1996: Continental Flight 1943 wheels up landing at Houston; failure to use checklist
16 Aug 1987: Northwest Flight 255 crashed from Detroit Metro Airport after attempted no flap/no-slat takeoff
Numerous sources, see e.g.,

52. Consequences of failure to use checklists
20 Sept 1990: B B N320MJ, failure to notice right rudder trim incorrectly set, A/C crashed on takeoff
31 Aug 1988: Delta Flight 1141 departed Dallas Ft. Worth without extending takeoff flaps, resulting from improper use of checklist
These are not isolated examples
Seehttp://aviation-safety.net/photos/displayphoto.php?id= &vnr=1&kind=C. For Delta 1141 seehttp://

53. Consequences of failure to use checklists
Checklist item: ‘Insert drain plug’ on pre-launch checklist

54. summary

55. Key points
Human errors account for the majority of accidents and fatalities in many fields, therefore, error management (avoid, trap, and mitigate) is key to safer operations
SOPs and checklists are proven tools for managing and reducing human errors

56. Key points
SOPs and checklists important for standardization, use of best practices, and communication
‘Bad’ SOPs or checklists are a problem and may lead to noncompliance
Writing good SOPs and checklists is difficult, but necessary
SOPs and checklists need to be periodically revised (e.g., when new equipment is added)

57. Key points: boating checklists
Several checklists have been published for recreational boats
But boat-to-boat differences make it difficult to develop a good generic checklist—there is no one size fits all!
Nonetheless published checklists and operating manuals are a useful starting point in developing customized checklists for each boat

58. Key points: boating checklists
Often boaters will be single-handed, which limits the ability to trap errors—nonetheless systematic use of checklists pays dividends
Consider using guests to help with checklist items and finally,
Keep all checklists readily accessible and make waterproof if necessary

59. Anxious to learn more?

60. Here are some good references

61. ?
Questions and Answers