Checklists are Broken
The following article written by Chauncey Chapman, has an interesting viewpoint on checklists and how they can be implemented in the most efficient manner. I’ll always argue that any checklist that works for you is a benefit, but he is absolutely correct in the view that a checklist can’t be too complicated won’t be used. I applaud Hollis for securing the “little yellow card” to all the CCRs they ship. It is a terrific signal to the new CCR user that we take checklists seriously.
From Chauncey:
One interesting tidbit I have heard is that in most rebreather incidents no checklist is found; on the unit, on the diver, or in the diver’s kit. None. So if Checklists were working, wouldn’t you expect to find a checklist in each rebreather diver’s possession?
We have been working to bring a rebreather to market; one of the efforts is to raise instructors to be qualified to teach our unit. We have had the pleasure of working with some very experienced rebreather Instructors and Instructor Trainers. The first thing we do in training is to introduce the Checklist and instruct the candidates to build up a unit. The Candidates dive into the kits and start building the unit, and for the most part ignore the checklist. Out of a hundred candidates a handful started with the checklists, the balance had to be reminded and prodded to use the checklist. We were providing a checklist that had 51 steps, and for each step there was a detailed instruction set explaining exactly how to perform the task. The Checklist was 4 pages long, and was expanded to 45 pages in the first version of the manual. We expected a diver to print the 4 page version out, take it diving, and use the checklist. Ha! It seemed that in our effort to make a better checklist we were making a checklist that no one wanted to use. Being an outsider to “tech diving” and rebreather instruction may have provided a different point of view through which to observe this dysfunctional effort. In making an honest effort to make the checklist a thing of value we were making the checklist something unwieldy and distasteful.
Ideally we would put the checklist in the rebreather controller. It would consist of key words, which when touched would expand in detail, and continue to drill down to photos or videos to help the diver get it right. In time with the familiarization that comes from repeated use, all the diver would need would be the keywords. Someday we will have this in the handset. So we started to develop a keyword checklist that we could print and hang on our rebreather. Something about this size of a business card. The concept behind this is training divers to use detailed checklists for setup and to use the key-word checklist just before entering the water. We kept the multi-page checklist, but we broke it into useful short lists. We kept the long detailed description of how inspect, setup, and pre-dive the rebreather in the manual. We solicited input from several IT that held high level credentials in rebreather training, had thousands of hours and lots of years of rebreather experience. We sent the proposed check list and a white paper that explained this was intended to be a short reminder of last minute lifesaving checks to be used by divers who had been trained in the detail behind the key words.
Almost everyone who replied added information. From a half page to three full pages of details, all good stuff like which way to rotate a valve hand wheel to open the valve; and they all missed the point. Which is to provide a reminder of tasks to do immediately before entering the water that will find faults in the rebreather’s life support functions.
This is what we came up with:
Pre-Breathe Checklist
1 Begin Pre-Breathe
2. Check ADV/BOV, Oxy Add, Dill Add, BC
3. Check SPG Oxy, Dil, OC
4 Observe SetPoint Maintanined
5. Always Know PPO2 & Have Fun
Please make your checklists useful, use them, and just before you enter the water, run through this Pre-Breathe Checklist.
