Shortly after airplanes started flying, airplanes started crashing. This is of course generally seen as a bad thing and soon the term “pilot error,” would enter our cultural vernacular and never go away (Gawande 32-33).
Flying a simple aircraft is actually a fairly simple process. You pull back on the stick and the houses get smaller, you push forward on the stick and the houses get bigger. But shortly after Orville and Wilbur put together their first contraption and a few pilots figured out the muscle memory to get it in the air, aircraft rapidly became far more difficult to fly – to the point that larger aircraft required more than one pilot and sometimes, an entire crew.
By the mid 1930s aircraft had gotten very complex and when the B-17 “Flying Fortress” was built the aviation industry had its first plane that was one process to many for one person to remember – thus, the checklist in aviation was born.
The list was simple, brief and to the point and small enough to fit on an index card (Gawande 34). In fact, my own penchant for using checklists came from my dad who to this day carries 3 x 5 index cards around with a list of things that need to be done. And even though I am a technophile with a iPhone, iPad, iAttitude, iCoppafeel (okay, I made up the last two), I still find myself using an old-fashioned 3 x 5 card to remember some basic things. It works because it’s SIMPLE, BRIEF and TO THE POINT.
- Much of what we do today has entered the B-17 phase. Substantial parts of many jobs require far more complex and numerable tasks for any one person to carry out reliably from memory alone (Gawande 34).
- In complex environments there are two main difficulties, first the fallibility of human memory and attention span, particularly with mundane, routine matters, and second is that people can skip steps even when they remember them (Gawande 36) – not every step matters and people figure that out.
- Checklists can provide protection against such failures but many people consider even the checklist to be mundane and boring (Gawande 38-39).
Checklists establish a higher standard of baseline performance (Gawande 39) by helping with memory recall and setting out the minimum steps in a complex process (Gawande 39).
But even checklists have limits. The key is to identify when a checklist can help and when they can’t. For example, while pilots live in a world of checklists, they also have certain “memory items.” Pilots are trained from day one in flight school about what actions to take when the engine quits. A pilot must act quickly to do three things which come down to aviate, navigate and communicate. First is fly the plane (aviate). Make sure you have enough airspeed to keep from falling out of the sky. Second, look for a place to land (navigate) and then alert others to your problem (communicate).
A pilot will also be trying to restart the engine. In a small plane, you don’t need a checklist for that as the basic steps are part of your memory, although one is available. In a large aircraft there could be several checklists depending on the type of engine trouble the plane is experiencing, but regardless, the first three items are always the same – aviate, navigate and communicate.
Apparently someone has studied the science of complexity – Brenda Zimmerman of York University and Sholom Glouberman of the University of Toronto have distinguished between three different kinds of problems: simple, complicated and complex (Gawande 48-49).
- Simple problems are ones that can be solved by essentially following a recipe. If followed, the recipe works every time in pretty much every situation and mastery quickly follows (Gawande 49)
- Complicated problems are like sending a rocket to the moon. There’s not a straightforward recipe and the problem often requires multiple people, multiple teams and specialized expertise (Gawande 49). But once you have sent the rocket to the moon you can repeat the process and begin to perfect it (Gawande 49). (Then conspiracy theorists can question if you ever really did it to begin with).
- Complex problems are like raising a child. Success in one experience does not guarantee success with the next. Expertise and prior experience is certainly valuable but still does not guarantee a successful outcome since each child is different and may require a different approach from the previous one (Gawande 49). And as a side note – NO KIDDING!!! But I digress.
You can no more create a checklist for how to raise a child, even though it seems many people try, than you can for how to run a country. Checklists however can solve many simple problems, particularly to prevent against carelessness or overlooked processes. Checklists can also help us be prepared for unpredictable turns and circumstances and to help us avert failure when problems move from the simple to the complex (Gawande 50-51).
You want to make sure you get the stupid stuff right. Yet you also want to leave room for craft and judgement and the ability to respond to unexpected difficulties that arise along the way – Atul Gawande 51
Did you ever wonder why we have to memorize so much stuff in school when you can just simply look it up? Particularly with the Internet where the information is available at our fingertips? Can’t we take the same rationale and say why do we need to remember how to do a lot of things if we can just replace them with the checklist?
The answer in both cases is that the process of memorizing this data is that it provides us context and builds muscle memory so that we can act on the information at the right time (plus we won’t look like tools in our professional circles and more importantly, we can win bar trivia games). As a pilot, the checklist will tell you what power settings you need and the steps to take to restart an engine but you if you have no idea where the controls are, or the right buttons or switches to turn or gauges to monitor the checklist really does not matter. So keep studying, but to build context and essential memory items – then build your checklists.
For a checklist to be highly effective you need to understand the core processes behind it. As a pilot, while you are running through your checklist trying to figure out how to restart an engine or fix whatever the problem is you cannot forget to aviate, navigate and communicate. Once you understand that, then the checklist can help you not to forget the simple functions (checking your fuel) and complex (configuring the plane in its best glide configuration), and sometimes even complicated functions, like landing a plane in the Hudson River.
Gawande, Atul. The Checklist Manifesto: How to Get Things Right. New York: Metropolitan, 2010. Print.
