Experience and Memory

Experience and memory:  Are they good enough to combat human error?

Are you supplying your team with the tools they need to excel as a high reliability organization when failure is not an option?  Do your front line workers have “Usable” procedures to ensure that they don’t miss critical steps, or are they forced to rely on their memory?  What we have witnessed in many industries like Oil and & Gas, Manufacturing, Transportation and Medical is a complete reliance on experience versus standardized, usable procedures.  When procedures do exist, they are rarely updated, rarely referenced, and are usually found sitting on a shelf in a dusty binder.

While having an experienced workforce is extremely valuable, relying on an experience based culture was abandoned by the airline and nuclear community over 50 years ago.  They learned that the volume and complexity of what we know has exceeded our “individual” ability to deliver its benefits safely and reliably.  They discovered that the best way to manage this complexity was with a standardized, procedural baseline without which it would b impossible to:

  • Ensure that workers remember critical steps
  • Ensure tasks are completed correctly the first time, every time
  • Provide operational help including pictures, videos or schematics to workers during a job
  • Integrate risk analysis with procedural steps
  • Provide a standardized method for addressing emergency procedure
  • Capture lessons learned and best practices
  • Measure job variability and efficiency
  • Establish a procedural baseline for continuous improvement
  • Transfer knowledge and expertise from one generation to the next
  • Provide a company-wide training standard
  • Verify process compliance to customers

What is the emotional value of operating like a well-oiled machine?  In 2015, the global commercial airline industry flew 3.5 billion people on 37.6 million flights averaging only one accident for every 3.1 million flights.  That’s 99.999964% reliability world-wide.

Demonstrating even better performance, the US Navy launched its first nuclear powered submarine in 1954.  Recognizing that even one nuclear accident was unacceptable, every effort was made to trap human error.  Since that time the U.S. has operated over 100 nuclear submarines, aircraft carriers, and cruisers without a single nuclear accident – 100% reliability.

What is the dollar value of increasing your organization’s reliability to 99.999999% or even better?  What would the impact be on safety, productivity, efficiency, rework, and maintenance down time?  By committing to a procedural based culture and focusing on trapping human error, the airlines and the U.S. Navy proved that six sigma reliability is achievable and repeatable.

When did we realize that experience might not be good enough?  On October 30, 1935, the U.S. Army Air Corps held a flight competition for its next generation long-range bomber.  Boeing’s Model 299 aircraft was expected to win as it could fly faster and farther than the competition.  The Army brass watched as the plane roared down the runway, lifted off smoothly, and climbed sharply to three hundred feet.  Then it stalled, turned on one wing and crashed in a fiery explosion.  Two of the five crew members died, including the pilot, Major Ployer P. Hill.  An investigation revealed that the crash was due to “pilot error” as Hill had forgotten to release a new locking mechanism on the plane’s flight controls.  Deemed “too much airplane for one man to fly” the plane lost the competition and Boeing nearly went bankrupt.

Undaunted, a group of test pilots came up with a solution.  Training was ruled out as Major Hill was the Army’s most experienced test pilot.  Instead, they created the first pilot checklist containing step-by-step checks for taxi, takeoff, flight, and landing that improved performance with no increase in skill.  With the checklist in hand, the pilots went on to fly the Model 299, a total of 18 million miles without one accident.  The Army ultimately ordered almost 13,000 of the aircraft, which it dubbed the B-17 Flying Fortress.

Through digital checklist use, CAVU International can help your team establish a higher standard of Performance and start the journey towards a standardized, procedural based culture.

We can work with your team to create checklists that accomplish what checklists have done elsewhere, help with memory recall and clearly set out the minimum necessary steps in a process.  Our coaches bring decades of experience in successfully leading and operating in complex, high hazard environments including commercial and military aviation, nuclear ship propulsion, conventional and special forces, and the Oil & Gas industry.

About the Author:  Terry Barrett, COO of CAVU International served 20 years as a US Navy Test Pilot.

For more info visit: www.CAVU-Intl.com or www.linkedin.com/in/terrysbarrett


  1.  The International Air Transport Association (IATA) 2015 safety performance of the airline industry.
  2.  The Checklist Manifesto, How to get things right, Atul Gawande
  3.  How the pilots checklist came about, Russ Davoren, www.atchistory.org


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