During my quality assurance days, I was always impressed whenever the company I was auditing included checklists in their inspection procedures. These companies had systems that often were more robust and were cited with nonconformances less frequently.

According to Atul Gawande in his book “The Checklist Manifesto,” a checklist provides a different strategy for overcoming failure, one that builds on experience and takes advantage of the knowledge people have but somehow also makes up for our inevitable human inadequacies. And there is such a strategy – using a checklist – though it will seem almost ridiculous in its simplicity, maybe even crazy to those of us who have spent years carefully developing ever more advanced skills and technologies.

History

The Pre-Flight Checklist is considered by most historians to be the “original” or “first” type of checklist. Like so many of humankind’s greatest achievements, it was born out of necessity – and tragedy.

As Alexandra Franzen relates in her book “The Checklist Book,” “On Oct. 30, 1935, at a field near Dayton, Ohio, Boeing Aircraft had planned a very special presentation for the U.S. military. It was the grand unveiling and debut flight of the Model 299, also known as the Boeing B-17 Flying Fortress.   Boeing was hoping to dazzle the U.S. Army Air Corps with this exquisite new plane, thereby securing a lucrative military contract. Things do not go as planned.  Tragically, the plane lifted off, climbed for a few seconds, then nose-dived into the ground – killing two people.

Three others were rescued from the wreckage. A horrific tragedy for the families of those who were lost, not to mention, a huge embarrassment for Boeing. What went wrong? Was it a mechanical malfunction? No. Inexperienced pilots? No. After a thorough investigation, the sad truth came forth. The fatal crash happened all because the flight crew failed to do one crucial step: release the flight control gust locks. Why didn’t they do this step? They forgot. Simple as that.  

They had too many steps to remember and they just forgot one. After this catastrophe, Boeing vowed, ‘Never again.’ They developed a new system: the Pre-Flight Checklist. By completing this checklist, every vital step would be completed. Nothing would be skipped due to negligence, distraction, tiredness, forgetfulness or any other human frailty.”  

 There were the checks they do before starting the engines, before pulling away from the gate, before taxiing to the runway and so on. In all, these took up just three pages.

The rest of the handbook consisted of the “non-normal” checklists covering every conceivable emergency situation a pilot might run into: smoke in the cockpit, different warning lights turning on, a dead radio, a copilot becoming disabled and engine failure, to name just a few. They addressed situations most pilots never encounter in their entire careers. But the checklists were there should they need them.

Pilots made their lists simple, brief, and to the point — short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing and taxiing. It had the kind of stuff that all pilots know to do.

Four generations after the first aviation checklists went into use, a lesson is emerging: checklists seem able to defend anyone, even the experienced, against failure in many more tasks than we realized. They provide a kind of cognitive net. They catch mental flaws inherent in all of us – flaws of memory and attention and thoroughness. And because they do, they raise wide, unexpected possibilities.

Value

Most of what lawyers, clinicians, financial managers, factory workers or software engineers do today is too complex to execute from memory. Most professional fields simply have too much for one person to handle. A checklist may sound simplistic, especially for clinicians who have to handle thousands of different conditions. But the vital signs nurses check for every hospital record such as pulse, respiratory rate, blood pressure and body temperature make up a simple yet indispensable checklist. In complex environments, faulty memory combined with the strain or distractions of the job can easily cause an expert to skip a key step in a process.

In processes where missing one step has the same consequence as missing all steps – as is the case in preparing a plane for takeoff, performing a complicated manufacturing process or checking a patient’s vitals—entire projects and lives can hang in the balance. Even when one remembers to perform every check, the relative unimportance of one step may lure an expert to skip it. Checklists guard against the consequences of faulty memory and mitigate the temptation to overlook steps that don’t always matter.

Final Thoughts

You might wish to consider compiling a daily checklist.  Alexandra Franzen suggests that the purpose is to help you:

• Feel calm, focused, and organized as you move through your day.

• Make a plan for your day that reflects your personal approach to life, a plan that feels meaningful to you.

• End each day feeling proud of yourself – with a visual record of all the things you’ve accomplished. Ideally, your daily checklist is short enough to fill just one sheet of standard 8.5” x 11” paper. One day. One page. Not multiple pages.

Max Sherman is a medical writer and pharmacist retired from the medical device industry.  His new book “Science Snippets” is available from Amazon and other book sellers. It contains a number of previously published columns.  He can be reached by email at  maxsherman339@gmail.com.