Why do we complete checklists?

In my most recent book, Paper Safe: The triumph of bureaucracy in safety management, I explore how bureaucracy has come to characterise most of what people recognise as modern-day health and safety management. I am particularly interested in how health and safety process – the activity of managing health and safety – has become disconnected from purpose – keeping people safe.


Often, when people think about bureaucracy in health and safety management they think about long, convoluted and difficult to understand policies and procedures. However, bureaucracy can be subtler and more insidious.


Take for example the ubiquitous checklist.


Is it a good idea to check plant and equipment before using it, to make sure it is serviceable and safe? Yes, I think it is.


Is it helpful to have a checklist or some other guidance information which identifies what I should look for, and perhaps any safety critical elements? Yes, I think it is.


But what is the value of asking a worker to tick off or initial each checklist item, then sign and date the document?


Does it add to safety? Does it provide assurance? Does it give us any legal protection? No, I do not think it does.


It may be the physical act of completing a form helps a person focus on the items they are reviewing, or there could be some cognitive or psychological advantage to going through the process of completing the paperwork. If that is right, then this could justify the paperwork. However, no one ever explains their checklist process to me in terms of psychological benefit. People justify (or tolerate) checklists based on things like client requirements, regulator expectations or “evidence”.


Before I look at the issue of evidence, consider the possible negative contribution that checklists make to your organisation. Do you think workers enjoy doing the same piece of paperwork every day for familiar tasks, or does it just irritate them? Could it irritate them to the point of distraction or frustration which impacts on their ability to work safely?


Do you think a regime of demanding workers complete checklists, checking they are completed and measuring compliance rates against completion increases trust between workers and management or decreases it?


How much time and effort (i.e. money) does your organisation expend completing the paperwork, collecting the paperwork, reviewing the paperwork (perhaps), collating the paperwork, scanning and filing the paperwork? To what end, and to what benefit?


A completed checklist is not assurance. A completed checklist is not evidence that a “check” was done – it is merely proof a piece of paper was completed. Even if we allow ourselves the luxury of assuming a completed checklist means the check was done, it is not assurance that the check was done well, it is not assurance safety critical elements are “safe”, it is not evidencing the workers are trained and competent to do the inspections. It is evidence of an activity (process) it is not evidence of safety or competence (purpose).


What about evidence?


As evidence a completed checklist is almost wholly irrelevant. A piece of paper a worker has ticked to say they checked an item on a piece of equipment is no more compelling or persuasive than the worker saying they checked the item.


If a worker was supposed to have checked a piece of equipment before using it, and there is a catastrophic failure of that equipment, there are several scenarios we might explore in the context of the pre-start inspection. For example, the worker might not have done the inspection. The worker may have done an inspection, but not done it carefully. The worker might have made a mistake.


If the worker did make a mistake during their inspection, it might have been a reasonable mistake, but it also could be unreasonable or negligent.


The worker might not have been trained or competent to do the inspection, or the item “missed” during the inspection might have become “normalised” – the guard has always been held on with a piece of bailing twine.


The worker may have raised hazard reports on their inspection checklists in the past, but they were never rectified, so the process has become meaningless to them.


Irrespective, when we are trying to work out what happened, for the most part the checklist is irrelevant. What evidence is relevant?


The evidence of the worker and what they say? Definitely.


The evidence of other workers and how they would normally complete a pre-start inspection? Absolutely.


The evidence of supervisors about how often they oversaw inspections? Certainly.

Maintenance records? Yes.


The evidence of experts who can give a technical explanation of the failure? Yes.


Other objective evidence, having regard to the nature of the failure, what failed, the mechanisms of failure and so on? Yes.


Whether a worker says they checked an item, or they have a piece of paper with a tick box saying they checked the item is irrelevant to all these considerations. It barely qualifies as a start point.


Ironically, and more problematically, while employers often collect checklists as evidence of their safe practices, the collection of checklists is more commonly used against employers to demonstrate their lack of due diligence and safety oversight. When you have a piece of equipment which catastrophically fails, and the objective evidence shows it has been unserviceable for a significant period of time, yet you have months and months’ worth of checklists showing the equipment is “safe” it is not difficult to draw conclusions such as:


  • The employer was not paying proper attention to their own safe systems of work, or


  • Employer did not provide adequate supervision to ensure that their systems of work are effective to manage the health and safety risks in their business (i.e. they did not manage risks as low as reasonably practicable).


So, it is at least arguable that completing, collating and collecting checklists negatively impacts workers, uses significant organisational resources, provides no health and safety assurance, adds no benefits to legal risk management and increases legal risk.


Why do you complete checklists? Might there be a better way to achieve the purpose?

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