“The volume and complexity of what we have to deal
with have exceeded our ability to remember what to do.”
~ Atul Gawande
On October 30, 1935, the US military was evaluating Boeing’s Model 299 bomber when something went terribly wrong.
The bomber made a normal taxi and takeoff. It began a smooth climb, but then suddenly it stalled and fell. It exploded in a fireball when it smashed into the ground, killing two of the five crew members, including the pilot.
The subsequent investigation revealed that the plane had stalled because the elevator and rudder controls were locked.
The locking mechanism was controlled from the cockpit, but no one remembered to disengage it before takeoff.
The investigation ruled that the crash was the result of pilot error.
Too Much Plane to Fly?
Because the Model 299 more complex than any previous aircraft, the newspapers reported that it was “too much airplane for one man to fly.”
But the problem was not the physical complexity of the Model 299. It was simply too complex for the limits of human memory and attention. What was needed was some way of making sure that everything was done, that nothing was overlooked.
So, the pilots put their heads together. They created a set of checklists for four key phases of flying: takeoff, flight, before landing, and after landing.
With the use of checklists and rigorous training, the Model 299 became the number one strategic weapon of the U.S. Air Force during World War II.
It was renamed the Boeing B-17 Flying Fortress and it soon developed a legendary reputation for toughness based upon stories and photos of badly damaged B-17s safely returning to base.
The B-17 dropped more bombs than any other U.S. aircraft in World War II and it flew over 1.8 million miles during the war without a serious accident.
Checklists in Healthcare
Atul Gawande, a surgeon at Brigham and Women’s Hospital is an expert on reducing error, improving safety, and increasing efficiency in surgery.
In his book, The Checklist Manifesto, Gawande gives several examples of how using checklists in the medical field has produced startling results.
For example, one-third of the time doctors were skipping one of the five critical steps in avoiding infections with catheters. The result was that eleven percent of the time there were infections.
The solution was to have I.C.U. nurses use a checklist to monitor what the doctors were doing and report anyone cutting corners.
“The new rule made it clear,” Gawande explains, “if doctors didn’t follow every step, the nurses would have backup from the administration to intervene.”
The nurses were strict, the doctors toed the line, and within one year the infection rate had dropped from eleven percent to zero.
The Power of Checklists
Atul Gawande begins The Checklist Manifesto by making a distinction between not knowing what to do and not doing what we know we should be done because of the limits of human memory and attention.
No matter how much of ‘expert’ you may be, even the most basic, routine steps can be overlooked when you are busy or are under pressure.
But when we rely on a simple tool―a checklist―we are forced to pay attention to all the routine steps. In short, the checklist supplements the failings of our brains.
In a world of compounding complexity, you need a simple, practical way to make sure that everything is done; that nothing is overlooked.
To ensure that you get everything right every time, just remember one thing: Check Your Checklist.
“OKRs have helped lead us to 10x growth, many times over They’ve kept me and the rest of the company on time and on track when it mattered the most.” ~ Larry Page, Google co-founder
At the end of an action cycle, there is a window of opportunity to learn how to improve next time.