Primeiro a curiosidade ("A introdução de uma checklist com 5 míseros passos... fez milagres!")
- "Uma simples checklist... "Já lavou as mãos?"" (Janeiro de 2008)
- "O poder da checklist" (Fevereiro de 2009)
- "O poder das checklists" (Junho 2011)
- "A merecer exploração" (Maio de 2012) onde se pode ler:
"Comecei a pensar, como é que conseguimos pôr os trabalhadores a fazer o mesmo no início de cada intervenção? Como os pôr a realizar uma preparação?Depois, a descoberta de que as checklists podem ser a oração:
Como conseguir pôr um grupo de velhos lobos-do-mar, tarimbados por anos e anos de experiência, moldados na nossa cultura de desenrasque e facilidade, a "rezarem a sua oração" antes de iniciarem um trabalho?"
"launched us into an exhaustive study of how to reduce these kinds of errors. After rejecting things like more training, and more supervisors, (Moi ici: No livro esta parte está mais desenvolvida e eu não pude deixar de recordar, como auditor, as milhares de respostas a pedidos de acção correctiva que são rapidamente despachadas com mais formação ou mais supervisão) we realized the problem was that of engaging brain before acting.Por fim, o mesmo tipo de recepção que as checklists tiveram:
We decided that when operating a nuclear-powered submarine we wanted people to act deliberately, and we decided on “take deliberate action” as our mechanism. This meant that prior to any action, the operator paused and vocalized and gestured toward what he was about to do, and only after taking a deliberate pause would he execute the action. Our intent was to eliminate those “automatic” mistakes. Since the goal of “take deliberate action” was to introduce deliberateness in the mind of the operator, it didn’t matter whether anyone was around or not. Deliberate actions were not performed for the benefit of an observer or an inspector. They weren’t for show."
"I believe “take deliberate action” was the single most powerful mechanism that we implemented for reducing mistakes and making Santa Fe operationally excellent. It worked at the interface between man and machine: where petty officers were touching the valves, pumps, and switches that made the submarine and its weapons systems work. TAKE DELIBERATE ACTION is a mechanism for COMPETENCE.
But selling the crew on this mechanism’s value was hard going.
One problem in getting the crew to perform deliberately was the perception that deliberate action was for someone else’s (a supervisor’s, an inspector’s) benefit. Even though we continuously talked about how deliberate action was to prevent the individual from making silly mistakes, I would overhear sailors discussing deliberate action among themselves in this misperceived way."