The Flying Fortress And Your Checklists
The B-17, nicknamed The Flying Fortress, has become a symbol for American air power in World War II. It was a high flying (35,000 feet) bomber that cruised at 170 mph but could reach speeds of 300 mph. It also could be defended with thirteen .50 caliber machine guns in multiple ports for use by six gunner crewmen. It was heavy and durable and brought most of its crews home safely in spite of enemy fire, damaged parts and belly landings. It attained a mythical reputation and was the plane of choice for many WWII movies. (Have you seen 12 O’Clock High?)
There were far fewer B-17s than needed at the start of WWII, in large part because of the tragic death of Major “Pete” Ployer Hill in 1935, when the B-17 was Model 299–an experimental aircraft being tested at Wright Field in Dayton, Ohio.
Flying Without A Checklist
Major Hill had a career of distinction and service and was highly respected for his character and personal style. In 1932 he was assigned as the Chief of the Flying Branch of the Material Division at Wright Field. He was the chief test pilot and also provided oversight for hundreds of flight tests on potential aircraft purchases. On October 30, 1935, Boeing Model 299 was being demonstrated to key Congressional delegates and others. Major Hill (his first time flying the 299) sat in the left seat with Lieutenant Donald Putt (the primary Army pilot for the previous evaluation flights) as the co-pilot. With them was Leslie Tower (the Boeing Chief Test Pilot), C.W. Benton (a Boeing mechanic), and Henry Igo (a representative of the engine manufacturer).
The plane took off just fine and began to climb but suddenly stalled and crashed. Hill died of injuries sustained in the crash and the others had serious burns. Leslie Tower died several days later. An investigation showed pilot error: The various operations for take-off were complex and Major Hill apparently forgot or did not realize that Model 299 had a “gust lock” on the elevator (the part of the plane that controls the nose up or nose down orientation of the plane). He did everything correctly before take-off except for releasing the lock.
The Congressional delegation advised against purchasing the aircraft because it was “too complex for one man to fly”. However, a few were purchased for the B-17 position in the Air Force fleet. The Air Force was concerned that another accident would cause the aircraft to be taken out of service permanently, so a group of Air Force pilots and Boeing mechanics and pilots were given the task of allaying fears about it. Their solution was to develop a list of the equipment that had to be in place and the actions that had to be done before take off, as well as lists for in-flight, prior to landing and after landing.
The list would be in the cockpit and the co-pilot would read each step then wait for the pilot to check the status and verbally indicate it by saying “Check”. If the co-pilot couldn’t make a check mark everything stopped until the situation was corrected. The flight checklist worked perfectly and made flight activities more organized. Soon, other pilots heard about the idea and developed checklists for their own planes. Within a short time it was required for all pilots in all aircraft.
Eventually Boeing was given contracts for a significant number of B-17s, but this delay meant the United States was two years into WWII before the Air Force had a sufficient number of the bombers. Production on the B-17 set records for large aircraft and required 24 hour shifts of mechanics and laborers–including many women who became part of the “Rosie the Riveter” story in WWII. Only 200 B-17s were in use at the beginning of the war and over 12,000 of the aircraft were built by the time production ended in 1945.
The lessons for us in the crash of Model 299–The Flying Fortress
1.) The B-17 wasn’t too complex for one person to fly. However, it was too complex for one person to remember everything that needed to be done. Seven items, give or take an item or two, is about the maximum we can remember easily. If the items are complex or unfamiliar, three is about the maximum. (Think about the implications for trying to teach or learn a task with several steps. )
2.) A mental checklist can be helpful–but it requires memorizing the checklist, which consists of the steps! When a task or series of tasks is crucial, use a written list and check each item as it is accomplished. (Think of the implications for safety, training and for avoiding calling a repairman who arrives and does the one thing you forgot again, then charges you $85.)
3.) Working with someone can help you stay honest about the list. If you are checking it yourself you might be inclined to move down it without ensuring each item is in place or each step has been accomplished.
4.) If you are developing a checklist, work with the people doing the task to produce it. Do not leave it entirely up the them, since often those who do a task jump the steps mentally, but let them contribute to it.
5.) The checklist was developed because someone higher-up wasn’t satisfied. I wonder if the pilots grumbled about Puzzle Palace interference? Do you think they would have developed a checklist if they hadn’t been trying to overcome opposition?
6.) Why was Major Hill flying that day? This one isn’t related to checklists, but needs to be mentioned: Major Hill was a fine pilot and so was Lieutenant Putt, who went on to become a Lieutenant General and the Director of Research and Development for the Air Force–and he had flown the plane several times. So, why was Major Hill flying that day?
It could be that Major Hill was required to fly for such a crucial demonstration. Or, it could be he wanted to fly to make sure nothing went wrong–and he trusted his own skills for that. It could be he simply wanted to be in on a big event of that nature. We will never know that part of the story. But, this can be said without a doubt: If he had gone through orientation training with either Lieutenant Putt or Mr. Tower, the Boeing pilot, he would have known about the gust lock. If he had known about it perhaps he would have disengaged it, flown a perfect flight, sold the Congressmen on fully equipping the Air Force fleet and the early days of WWII might have been different–and he and Mr. Tower might have lived long lives, enjoying their memories.
Consider the implications for that when you feel the need to show that you know the job as well or better as those who are doing it every day. You may have once been an expert but things change. Make the assumption that you will always benefit from refresher training–and the same applies to anyone who has not done a task for awhile.
7.) Think about the checklists that could benefit you and your work group:
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When a task or process is too important to leave anything out even once: Make a checklist and train, test and evaluate with the requirement that it be used every time.
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Even if you don’t institute a checklist for tasks: Consider frequent refresher training, including having the people who will be doing the task explain what they do and why they do it.
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Make a list of the steps involved in the action on the computer or other equipment that you always seem to forget. Use the checklist so you don’t have to call someone to help you so often.
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Have checklist for your fitness routine. Checking each exercise or activity off is motivating and prevents lapses.
- Keep a list by the door at home and work: It will keep you from turning around and going back–or doing without.
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Post lists next to equipment or in areas where a task is performed: Employees can easily follow all the steps in the right order.
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Have trainees develop checklists of the multi-step tasks with which they are having problems.
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Tape, pin or place checklists: Put them inside your briefcase, suitcase or the trunk of your car.
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Use checklists in testing: Leave out a few steps in a list and have trainees provide them.
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What else?
The bottom line about the Flying Fortress and your checklists: Would you want the person piloting a plane in which you were flying to not use a checklist? What if the pilot resented being micromanaged in that way? What if the pilot said he or she knew the processes for readying the airplane for take-off and didn’t need a checklist? What if the co-pilot said it was a big hassle and took up too much time? You know the answers!
