On point

All aboard!

If you’ve ever boarded one of Japan’s efficient, modern trains, you may have seen a railway employee, dressed in an impeccable uniform, making hand gestures and calling loudly as the train approaches or departs the platform. Similar gestures and calls are also made by the train’s engineer and conductors throughout the train’s operation. This is a system Japanese railway workers developed to ensure that no vital task is overlooked. Known in Japanese as Shisa Kanko, Shisa Kakunin Kanko, or Yubisashi Kosho, it’s translated into English as “pointing and calling.”

This occupational safety technique was first used by Japanese train engineers in the early 1900s when they would call out the status of track signals. Today, it’s used by all Japanese railway employees, as well as many industries throughout that country. It’s a system of making large gestures and speaking the status of an item or task, helping to focus the worker’s attention. A study by the Japanese Railway Technical Research Institute found that this simple act of pointing and calling reduced mistakes by 85 percent when used during a simple task.

A graphic posted on the Japan International Center for Occupational Safety and Health website illustrates the process and lists the steps:

1. Look at the object—State the item to be confirmed.
2. Point at it—Extend your right arm straight. Point at the object with your index finger.
3. Raise your right arm to your right ear—Make sure it is OK [a note adds: You must make sure it is really OK while you raise your right arm to your ear].
4. Bring your hand down—Confirm the appropriateness of the object. Say “OK.” Bring your hand down, pointing at the object.

This method might be a bit cumbersome for use in a cramped cockpit, but the basic idea is sound. Pilots might want to think of it as a three-step process, perhaps like this:

1. Point at and say the object, “Altimeter!”
2. Raise your hand up to your ear—this gesture should remind you to “think if this is correct and sensible.” Think and speak out loud, “Current barometric pressure is 29.85!”
3. Point again at the object and confirm, “Altimeter is set to 29.85, OK!”

Touchy feely

Some flight instructors have told me they use a hands-on method, very similar to pointing and calling, in which they teach students to touch every item as they address it. During a pre-start checklist that would mean putting a finger, gently, on every instrument and switch as the pilot checks its status and sets it appropriately.

These CFIs also teach pilots to keep their hand on any control they’re manipulating, until they’ve achieved the desired result. For example, when reducing power on approach, a student will be taught to keep his hand on the throttle lever until he has confirmed that the engine has throttled back to the appropriate rpm and is holding there.

Take the “P”ointing train

You would think any system that reduces mistakes by 85 percent would immediately be adopted by other industries and become a common practice around the world. Unfortunately, pointing and calling has not become mainstream outside of eastern Asia. Another place where the system is used is the New York City subway system. The New York’s Metropolitan Transportation Authority introduced the concept of “pointing” to train conductors in 1996.

On every subway platform facing the train is a black and white striped sign. When the train stops in the correct spot, a “zebra” sign is directly opposite the conductor’s window and she knows the train is fully in the station. No rider will step out of a train car and fall onto the tracks. The striped boards have been mounted on the subway platforms since World War I, when a system was installed allowing one conductor to operate all the doors on a train. However, according to the MTA, it wasn’t until “September of 1996 when conductors were first required to physically acknowledge the ‘zebra boards,’ by pointing to them before opening the doors. This was done to create an additional level of safety. By pointing at the board, the conductor acknowledges that the train is stopped at the proper spot on the platform. While there is some fogginess over just who made it a requirement, there is absolutely no argument over where it originated—Japan.”

Saving the B–17

Some pilots have heard the story of why the first aviation checklists were developed. In 1935, there was a fatal crash of a prototype for the Boeing B–17 Flying Fortress. It occurred because the pilot, a man with great experience, forgot to release the elevator gust lock before takeoff. Reporting on the accident, some newspapers called the complex four-engine bomber “too much plane for one man to fly.” The engineers and test pilots at Boeing didn’t think it was too much airplane—just too complex for a pilot to remember everything needed to ensure safe operation. So, they wrote out a list of all the tasks to be completed, and items to check before takeoff, and that became the first pilot’s checklist.

Actually, four checklists were developed: for takeoff, in flight, before landing, and after landing. Boeing convinced the U.S. Army to continue evaluating the experimental bombers—tests in which they flew almost 2 million miles without a serious accident—and thanks to their performance, and the impending war, more than 12,000 B–17s were built.

The concept of checklists in aviation spread rapidly, first to other positions on the B–17; then to other military aircraft; and, after the war, to commercial aviation.

The Dr. God complex

Recently, I saw a magazine cartoon of a patient listening to his doctor in an exam room. The doctor was saying, “Do I think I’m God? God-like, yes, but not God.” That sounds like some pilots before the days of cockpit resource management, when a lowly co-pilot didn’t dare question the decisions of an all-knowing captain.

In 2007, a doctor concerned with medical safety, Atul Gawande, related the story of the B–17 bomber checklist in an article for The New Yorker about how checklist use might relate to medical treatment:

“Medicine today has entered its B–17 phase. Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone.”

He told the story of how a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost set out in 2001 to tackle the problem of line infections. “On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So, it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

“Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: The 10-day line-infection rate went from 11 percent to zero. So, they followed patients for 15 more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented 43 infections and eight deaths, and saved two million dollars in costs,” the article stated.

Johnny mnemonic

Pilots use both mental and written checklists, but research has shown that the limit for accurately remembering a list of items, in order, is about nine. More than that, and mistakes of omission and order are inevitable. During an emergency, airline pilots are taught to run through a quick mental checklist, while the co-pilot reaches for the written one.

To assist in remembering these checklist items, many pilots use mnemonics. A mnemonic, also known as a memory device, is any technique or strategy to improve memory. The most common mnemonic pilots use is the acronym, which is a word formed from the first letter of a phrase or list of words, such as NASA for National Aeronautics and Space Administration. Don’t confuse any acronym with a mnemonic; a mnemonic is any technique or strategy to improve memory, and there are many more than I can list here.

Perhaps one of the most well-known mnemonic acronyms used in aviation is GUMPS, which is an easy way to remember a before-landing checklist: Gas, Undercarriage, Mixture, Propeller, Seat belts/Switches. It’s taught to most flight students and even encouraged by the FAA.

Effective mnemonics contain no more than nine items. Always use a written checklist any time the number of tasks exceeds how many fingers you have. Remember, it was the number of items to be checked that doomed the experimental B–17 bomber, not the complexity of the tasks.

Meanwhile, back at the bar, the pilot, surgeon, and engineer agree that any technique that improves the consistency of their work is a good thing. Remember that the reason for all these techniques is that you can’t remember all the tasks you must remember to keep your piloting safe and correct. Remember? Memory is fickle and while flying we need to use any resource available to ensure nothing is overlooked. Like an elephant, a checklist never forgets. Unlike elephants, pilots do.