John Crossan | Manufacturing Ownership Blog
Why Won't We Use Checklists? PDF Print E-mail
Written by John Crossan   

Over the years, as have many others, I’ve spent a lot of time in discussion, debate (argument?) in plants, over the use of checklists for equipment changeovers,  startups and other processes. I have explained, reasoned, rationalized, cajoled, appealed, beseeched, entreated, implored, pleaded, urged, (ratiocinated?) and I’ll swear, even cried real tears, in efforts to get people to use checklists.

So for me it was great to find discussions, , referencing a study published in the New England Journal of Medicine that found (amazingly?) that hospitals using checklists in their operating room procedures suffer a much lower death rate than those that don’t.

I was glad to see the study, but still my very first reaction on reading it, was really outrage, along the lines of “Why was a study like this even necessary? Operating Rooms don’t routinely use checklists?  What the (expletives deleted)?"
Hopefully the study will ratchet up awareness some and perhaps drive some improvement. (This also gives some indication of the opportunity for improvement in the medical system.)

But experience has absolutely convinced me, that there is something in the human psyche that fights back desperately against using checklists.

“We need to get things done quickly. Checklists will slow us down. We know what we’re doing; we’ve done it a zillion times before.”

Best intentions in the world. Just not a correct statement.

Generally we found on packaging lines, that any missed item on a changeover checklist cost us at least 10 minutes of lost time on startup. In several cases it resulted in some really significant equipment damage, and who knows how many other times, there were damage near misses, or safety near misses. Settings that weren’t changed, bolts that weren’t tightened, clamps left loose,All completely unintentional, done by people who had done it many, times before.

Human memory just isn’t reliable enough, especially if interrupted to briefly do something else, or perhaps someone has a question, or needs a hand momentarily. Once the mind has changed focus, all bets are off on memory.(I'm still incredulous. How can hospital operating rooms not use checklists?)

A weakening memory in our culture seems to be treated as a real indicator of diminished capability, a sign of oncoming senility. the dreaded "senior moments"(An older friend I play golf with on occasion, describes dryly that in his experience, the older people get, the more of them it takes to have a conversation. With a big enough group, someone will remember what fills the blank the current speaker is struggling with.)

But human memory isn’t a reliable mechanism at any age. We all forget our keys, or where we left them, or "What did we come into this room to get?". I’ve seen even the smartest, most capable people I’ve worked with forget things when distracted.

I can understand why surgeons, renowned for the magnitude of their egos, would resist anything that seems to suggest a compensation for a failing capability. But why then have airline pilots (with at least, comparable egos?) accepted checklists for many years. (Well yes, the regulations say they have to, but if you talk to them, they say they just wouldn’t even think of operating without them).

My associate Mike Thomas, ( who was a navy pilot, and then a trainer of navy pilots and airline pilots for years, explains it as just a part of flying. From their very first exposure to airplanes, pilots work from checklists, and a key part of the trainer’s job is training in how to use checklists, just as much as training in the actual functions of the airplane.

Similarly in plants, we found when individuals are trained to perform tasks using checklists, they tend to continue using them. The difficulty comes when someone has been routinely performing a task before the checklist is developed. Even if they help develop the checklist, it’s still difficult for them to begin using it.

And of course we always got the argument, that for pilots it’s a life and death situation. (Surgeons too?) And the same rigorous practices are just not necessary (and not affordable) in industry. But yet, always, when we started using checklists, things got better and faster.Well the simple answer then, of course, is we just make it a requirement for people to use checklists, and if they don’t, then there are consequences. (Whatever it takes, Seems to work for Jack Bauer.)

But if you absolutely insist that people turn in completed checklists, then you’ll absolutely get completed checklists, because that’s what you asked for.
Nothing says the checklist was actually used like it should have been. And unfortunately that’s the story behind much reported checklist use. The requirement was a completed checklist, so that’s what we got.

I have looked in many files and seen many pristine checklists, and PM workorders, without any fingerprints, or smudges, or stains, and wondered how people could manage to keep them that clean out on the floor.

North Americans historically, are not good at mindless obedience, but we are quite excellent at mindful disobedience, particularly when someone tries to force us to do something we don’t have much value for.

That’s the way people in this country are typically wired. (And I’m sure it’s becoming the case in most countries these days). We always push the limits, and we don’t take much for granted.
(You know just one thing wrong on that checklist, even a typo, negates completely the value of the entire thing. "Dude. This thing's totally hosed.")

We also had to talk about different ways to use checklists. If someone has performed a task countless times, it’s not very efficient for them to go step by step thru a detailed listing checking off each item as they do it. In that case ok to perform a small group of related tasks, then check them off. But it is never, never, never, ok to perform all the tasks, then check them off. (Gee. Did I do that one or not?).
(But oddly, it's not the beginner who benifits most from checklist use, it's the person who does do it all the time, as it becomes difficult for the mind to remember this time separately from the last time.)

I have counseled people “Why do you want to stress yourself, taking the risk of forgetting something? Why even try to remember? Use the checklist.” This is all about getting equipment started up and running well, as fast as possible, not completing mental improvement exercises.

Who deserves more respect? The person who uses the checklist, completes the changeover perfectly and the equipment starts up and just runs. Or the person who manages to do almost all those steps completely from memory, and then we burn time trying to get started.
If you want to win trivia games at home (or in bars), maybe even compete on Jeopardy, or otherwise exhibit incredible memory prowess, that’s great. But memory gymnastic demonstrations don’t help us with more effective, efficient equipment changeovers or startups.

(I remember a plant where the qualification requirement for operating a piece of equipment was to be able to change it over completely from memory. This was a big piece of equipment with way more than a hundred steps in the procedure. Got blank stares when I asked why?)

So what actually works?

  • Well the use of checklists has to be mandatory, beyond debate. Just like safety glasses, hearing protection, lock out safety, etc. they’re part of the job. But it takes much more than law and order enforcement to get successful ongoing use. (See mindful disobedience above)
  • Have to work with people and train them to do the job using the lists. Then it’s a routine, essential part of the process, and they get over the idea that it’s something extra, that’s slowing them down.
  • Have to be actually out there, making sure everyone has their checklist and is really using it. And finding any issues with the lists.(This is the easiest way to do mandatory)
  • We found laminated plastic checklists and grease pencils worked best
  • Changeover follow up meetings identify where people are struggling with the checklists, and identify time loss due to improper use. But we’re looking for improvement, not blame. (Blame tends to get you back again to mindful disobedience).
  • Last but most important. Have to have active, everyday, participative processes to continuously improve changeovers and startups that include keeping the checklists current, and so build ongoing ownership for them. It's amazing how ownership makes the whole process just so much easier. (It's ok to have some group develop the initial checklists, but for them to sustain, everyone has to have ownership for them.
    People pretty generally hate processes they don't have input into.) This is an essential part of Lean that is so often missed.

This means constant work for team leaders, supervisors, managers, but it’s an essential part of their job. And most importantly, they themselves, really have to believe that using checklists is the most effective, efficient approach.

(But it's really neat when more and more people become advocates).

Later I found this recent article that really develops the medical issue and gives some great history of the use of checklists.



  1. Great article ... very insightful! I posted a link to it at our blog: I think you will find many of our posts interesting and you might even enjoy one of our root cause analysis courses. I read your entry about causal analysis and using a "somewhat systematic" approach but I think you would find TapRooT® very usable and the training enjoyable. Thanks and please keep up the interesting reading! Mark Paradies President System Improvements, Inc.
  2. Now that Atul Gawande's book about checklists in medicine is out, he's on all the radio interview shows. Interesting that he doesn't use the word Lean or any other bits of jargon from manufacturing, but he's carrying the principles forward. Since they help reduce errors, they save lives, insurance settlements, and extra days of hospitalization. If anything will save healthcare, it's going to be practices like the checklist.