135: Inadequate Checklist
Definition/Typical Issues
If a checklist was necessary, was it confusing? Was insufficient room provided for the response? Did each instruction (regardless of format) fail to clearly indicate what was required? Was a detailed checklist required for a task that was not very important? Was an error made because each separate action in a step did not have a check-off space provided (for procedures that are complex and critical enough to require check-offs)?
Were incomplete or incorrect data recorded because numerous items were included in one step?
Examples
Example 1
- An operator failed to complete one step of a procedure. The procedure required a check at the completion of each step. Because it did not require unique responses for the steps, the operator completed the procedure and then checked off all the steps at one time.
Example 2
- A checklist was designed so that the desirable answer to most questions (23 out of 26) was yes. As a result, the three remaining questions were often answered incorrectly. An operator failed to open a valve.
Example 3
- The procedure required an operator to open seven valves. He missed one, opening the other six. A separate check-off space for each valve manipulation was not provided in the procedure.
Typical Recommendations
- Develop a checklist for all safety-critical tasks to provide a quick reference for inexperienced and experienced users.
- Require that checklists be turned in if necessary for quality assurance.
- Avoid using checklists instead of supervision to ensure that tasks are performed correctly because checklists can easily be filled out before or after the task; if supervision is required, then provide a supervisor.
- Include the unique system response to be expected when an employee completes each step of a checklist.
- Provide enough white space on the checklist so that the employee may record both expected as well as unexpected responses.
- Ensure that checklists are only developed for critical tasks. Overuse of checklists will reduce their effectiveness on critical tasks.
- For actions that require multiple steps, ensure that all the steps are specifically defined. When appropriate, include a check-off space for each of these individual steps so that the employee can be certain that he/she has performed this step.
- When the sequence of operations is important, or when it is important that certain steps be complete prior to moving to the next phase of operation, include a checklist in the procedure that the operator can use to mark that each step is complete.
Cross-References
| Version 10 Element(s) | |
|---|---|
| Node ID | Node Name |
| 121 | No Checkoff Space Provided But Should Be |
| 122 | Inadequate Checklist |
| Maritime Element(s) | |
|---|---|
| Node ID | Node Name |
| 128 | No Checkoff Space Provided but Should Be |