On Sat, 13 Sep 2003 12:49:15 -0400 (EDT), Henry Spencer
<[EMAIL PROTECTED]> wrote:

>The key word there is "FOLLOW", not "CHECKLIST".  The problem with
>paperwork-heavy organizations is that they start treating the paperwork
>as an objective in itself, rather than as a tool. 

Ack!  *Those* people should be put in stocks in the village square and
pelted with rotten fruit.

Following the checklist is not an acceptable substitute for thinking.
Until exactly the same crew has used exactly the same tools to do
exactly the same work on exactly the same equipment under exactly the
same conditions, with no anomalies, there is no acceptable substitute
for thinking.  I don't think the above has happened yet in rocketry.
I know it hasn't happened in carrier aviation - too much turnover -
and I doubt it's happened in commercial aviation in any but the
smallest outfits.  The world is a highly variable place, and
checklists can't keep up.

Not that it isn't the checklist guy's job to try, and everyone else's
job to help him.  A rocket checklist is a living document.  If the
documented way to do something isn't obviously the best way to do it
(which you don't always catch in rehearsals), you change the
checklist.  You then follow the changed checklist.  If it changes too
much, you should scrub for the day, go back and do the rewrites, and
come back out and work from a clean copy.  You can't always to do
that.

>Remember the time when a forgotten work-platform support went CLUNK inside
>an orbiter engine compartment as the orbiter was being tipped up to the
>vertical for stacking?  There were three signatures which said it had been
>removed.  None of those guys actually looked inside the engine compartment;
>they were just doing the paperwork.  What we have here is the flip side of
>that:  when the paperwork becomes a separate problem, people don't feel
>compelled to keep it current.

Good God.  Every one of them should have personally looked in there.
"Trust, but verify" *works*.

...It's a culture issue.  "I can skronk off - Joe will take care of
it."  If even a fraction of the crew thinks like that, the culture is
broken, and is not safe to fly, and no amount of paperwork can fix it.

In a decent organization, crewmen think, "I gotta do this right - if
Joe catches me out, he'll razz me about it for days.  I'll get Bob to
check me."  In a good organization, and I've been lucky enough to be
with three so far, everyone does it right because it's the right thing
to do, and nothing else even enters their mind.

-R

--
Son: Dad, I have a question about women.  Suppose I
Dagwood: Apologize anyway.
Son: Yeah, that's about what I figured
Dagwood: It saves time
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