Early design reviews gave the advantage to Boeing’s new Model 299. When the gleaming aluminum plane taxied out, a small crowd of army brass and manufacturing executives watched as the plane took off, stalled, turned on one wing and crashed. Two of the five crew members were killed.
On January 15, 2009, US Air flight 1549 taking off from LaGuardia Airport in New York City struck a flock of geese and wound up landing in the Hudson River. The media wanted a hero, of course, and Captain “Sully” Sullenberger was made out to be one. But he tried to deflect the praise to the training and professionalism of the entire flight crew. Perhaps the real hero was the system devised to fly that new Boeing 299 back in 1935—the checklist.
Atul Gawande describes these incidents and more in a book that tells the story of developing systems to prevent illnesses such as fatal infections after surgery. His book “The Checklist Manifesto: How to Get Things Right,” published by Metropolitan Press, is an entertaining read. It is also persuasive about finding better ways to work.
I confirmed with my son, who is a pilot, how the checklist system is used in practice on every flight. The system is not exotic. It doesn’t require a powerful computer. It’s simply a list of reminders. Sometimes you do things so many times repetitively that you don’t remember if you did one of the steps. By pausing occasionally and reviewing the checklist, you assure that you completed the essential steps.
There are defined protocols in the cockpit of an airline. I heard First Officer Jeffery Skiles speak about the experience on USAir 1549. Gawande also speaks to the experience. Skiles was “pilot-in-charge” of the flight. When things went wrong, Sullenberger the pilot said, “My plane.” That meant that he took the controls and Skiles went to the manuals. He knew from experience that there were two important things to do. He started the processes, then grabbed the checklist manual. He had less than two minutes, but he had prepared the plane enough for the water landing that the probability of success was dramatically increased.
Two types of lists
Gawande studied many other professions who create and use checklists. Construction project managers use two types of checklists. One is a list of tasks that must be accomplished before another task can start. The other is a list of people who must be included in the conversation when things go wrong.
He made a couple of key discoveries when applying the checklist idea to operating rooms. First, the checklist cannot be comprehensive. Second, its success depends upon teamwork and collaboration. When you are in a situation, your training must take precedence. The checklist cannot replace that. He discovered that what must happen is that there must be pause points where someone reviews the checklist, which is composed of just a few critical actions, and announces that everything is accomplished to that point that should be—e.g. the surgeon washed his hands or the antiseptic was applied. So both the list itself and the teamwork are critical.
I wonder how this would work in production and manufacturing operations. Dave Gehman, in his article on page 36, discusses new ways to display information. Next month Jim Koelsch will explore workflow tools. But what if there were a simple, tabbed manual that contained short checklists for operators or engineers to help them assure critical operations are performed in any abnormal situation?
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