I don't know about others, but I can't help but smile when I read the detailed series of events in aviation postmortems. To be able to zero in on what turned out to be a single faulty part and then trace the entire provenance and environment that led to that defective part entering service speaks to the robustness of the industry. I say that sincerely since mistakes are going to happen and in my view robustness has l…
The Checklist Manifesto (2009) is a great short book that shows how using simple checklists would help immensely in many different industries, esp. in medical (the author is a surgeon). Checklists of course are not the same as detailed post-mortems but they belong to the same way of thinking. And they would cost pretty much nothing to implement. Also CRM: it's very important to have a culture where underlings feel th…
I was a submarine nuclear reactor operator, and one of my Commanding Officers once ordered that we stop using checklists during routine operations for precisely this reason. Instead, we had to fully read and parse the source documentation for every step. Before, while we of course had them open, they served as more of a backstop.
His argument – which I to some extent agree with – was that by reading the source documentation every time, we would better engage our critical thinking and assess plant conditions, rather than skimming a simplified version. To be clear, the checklists had been generated and approved by our Engineering Officer, but they were still simplifications.