DZAC

October 30, 1935-Wright Field-Dayton Ohio

Flying Fortress-Model 299

Test Run Test was considered a formality Stalled at 300 feet 4 engines instead of the usual 2 Pilot was Chief of Air Corp Flight Testing Pilot had forgotten to release a new locking mechanism on the elevator and rudder controls Human Error

“Too Much Airplane for One Man to FLY”

How to Fly Advanced Aircraft Training-It was hard to imagine pilots having more experience and expertise New plane was too complicated to be left to the memory of any pilot

Pilot Safety Checklist Step by step checks for takeoff, flight, landing, and taxiing Emergency checklists Flew 108 million miles without incident Using the Checklist-A Sign of Strength

Checklists Thousands of hours are spent developing the checklists Flight controls checklists De-icing checklist Door FWD Cargo light checklist

Surgical Checklists Emergency rooms complex in the variety of cases seen Nurses/others were reluctant to correct Doctors ICU tasks 178 per day- such as putting in a central line

Failure Is Not An Option Nine story columns Wind tunnel testing reveled it was subject to wind steams and turbulence Four Hundred ton concrete block from huge springs in the buildings crown on the 59 th floor

“ The Biggest Cause of Serious Error in this Business is a Failure of Communication”-O’Sullivan Calculations behind the designs for stabilizing assumed the joints in the giant braces would be welded. Joint welding is labor intensive and expensive The contractor erecting the tower switched to bolted joints Changes were not reviewed with the architectural firm The checkpoint on the communication checklist was bypassed

Fatal Flaw Discovered 1978 A year later a Princeton engineering student asked question The building would not withstand 70 mph winds 2 inch thick steel plates were welded around two hundred critical bolts

Checklists-Tools to Buttress the Skills of Expert Professionals In complex processes certain steps don’t always matter Skipping steps can become habitual Occurrence Report Communication

Types of Checklists Safety Checklist JHA Permits AHD LOTO Work Order Information

The Checklist Manifesto