Why checklists are awesome

(An introduction to the history and usage of checklists)

In this article we’re going to see plenty of cool examples that illustrate how professionals in very different scenarios use checklists to improve their performance and save lives.

The main source for this article is Atul Gawande’s bestseller, The Checklist Manifesto. The author is a surgeon that helped the World Health Organization develop a checklist for hospital personnel to use before and after surgery. These new, extremely simple devices helped hospitals lower death rates and increased the doctors’ performance. In the book, the author also describes other uses of checklists in many different fields.

Ultimately, this is an eye opening book about complexity, and how we can face it. Highly recommended.


What’s a checklist, anyway?

(Or, a quick definition)

At first sight, a checklist is a simple list of items. In reality, it’s much more than a simple list of things we ought not to forget.

What is the necessary feature a list needs to have in order to be considered a checklist? Checklists are Essential. In a proper checklist, there are only a few, short items that get straight to the point. These are the 20% of the factors that will drive the 80% of the success of the action we need the checklist for. These are the few, crucial things.

As for the reason behind the existence of checklists, a quick trip to Wikipedia tells us that:

“A checklist is a type of informational job aid used to reduce failure by compensating for potential limits of human memory and attention. It helps to ensure consistency and completeness in carrying out a task.”

So the enemy here is human error. Checklists are meant to be employed when humans are most likely to fail: this may be because of panic, inexperience, excessive confidence or excessive complexity of the system they have to deal with. We will see plenty of examples in the next section. First, though, let’s wrap up the key elements of checklists:

  1. They are lists of things we need to be sure about. Like some kind of dumbed down algorithm, it’s a series of consecutive checks. If one fails, it must be completed before we can move further down the list.
  2. They are essential. They are meant to be easy and effortless to use. They have to help the user focus his attention on the task at hand, and try as hard as possible not be distracting and waste the user’s time with unnecessary actions.

Ok, we’re done with the basics. Let’s see some cool examples now.


Checklists that bombed Nazis

(Or, an introduction to checklist history and usage)

One of the most amazing results checklists brought to the table involves bombers and Nazi Germany. In the 30’s, the U.S. Army Air Corps asked the leading airplane manufacturers of the country to present the new generation bomber. The main competitors were the Boeing, the Martin and the Douglas aircraft companies. Boeing erased all doubts about the winner the morning of the test flights on October 30, 1935, when it unveiled its aircraft. The Model 299 held five times as many bombs as the army had requested, and could fly twice the distance of that time’s bombers at an higher speed: everything suggested the Boeing company was going to be the winner.

However, the test flight was a disaster.

The Model 299 after its test flight.

Among the many plane functions that had to be enabled and disabled during different flight phases, the crew forgot to release a new locking system on the elevator and rudder control. The plane lifted off, stalled and then crashed, killing two of the five members of the crew. A newspaper said that the Boeing Model 299 was

“Too much of a plane for one man to fly

Because of its increased size and four engines, among other things, the plane had become an incredibly complex system. Despite this debacle, the army saw potential in the plane, and went on to buy a few aircrafts as test planes.

In the following years, the Model 299 came to be the B-17, the “Flying Fortress”, as a Boeing trademark dubbed it, and was used extensively for military operation on both the European and Pacific theaters during WWII.

What was the factor that enabled this transformation of the Model 299 from test flight failure to the army’s most widely employed bomber? You can guess the answer.

After the test flight, the army put together a few test pilots and made them sit down to solve the complexity problem.

The solution they came up with was a checklist.

The checklist was made “simple, brief and to the point”. It could be printed on an index card, and it contained step-by-step checks for takeoff, landing and other flight phases. Instead of forcing new pilots to take longer periods of training, the test team decided to face complexity and get completely rid of human error by using a tool that was never before applied to their field.

Checklists are used in aviation to this day, and they look like this:

We have to make an important distinction here. The checklists used in the Flying Fortress were used to make it easier for the pilots to avoid errors because of the impressive degree of complexity of the plane they had to maneuver. Actions that came automatic to the pilots with other planes, like taking off and landing, were now made more difficult by the complexity of the plane. This is a general scenario: checklists are best employed in complex situations, where there are a lot of variables at play and where human error is most likely. However, we can make an additional distinction based on the two main kinds of aviation checklists used today:

  1. Routine checklists are somewhat the most classical example of application. Generally, once a professional repeats a task many times, it becomes second nature. When an action is performed automatically alertness fades, and this can be quite dangerous. Humans are prone to error, and overconfidence is an insidious enemy. This is the reason why takeoff and landing checklists exist.
  2. Emergency checklists, on the other hand, have as enemies the complexity of the system and the unknown nature of the situation. Panicked and scared minds may go for intuitive solutions that are actually not correct, or overlook critical problems. The need to handle these situations correctly led to the creation of emergency checklists that deal, in the aviation context, with failing engines and other problems that even experienced pilots may have never encountered.

If you are interested in more examples related to aviation, you can find additional resources at the end of this article.


Checklists that save and checklists that kill

(Or, surgeons and executioners)

During research for this article, it struck me that checklists really are an all-encompassing tool. Among the people using them, there are both people that try to save other people’s lives and people that need to make sure that people die, instead. Let’s look at these two sides of the same coin.

Surgeons

Atul Gawande writes in his book about how checklists applied to pre and post-surgery procedures can improve a patient’s chances of survival substantially. The results I’m going to talk about can be viewed here. Checklist efficiency is measured by comparing metrics like death and complications rates, before and after the employment of the checklist. Across the various hospitals in which the checklist was introduced, death rate after surgery fell from 1.5% to 0.8%. The expected complication rate went down from 11% to 7%. In one hospital, infections contracted during surgery went down from 20.5% to 3.6%. These results were achieved by using an essential list of checks a nurse has to go through before each operation.

Among the various “technical” checks, like making sure the patient had been given antibiotics some amount of time previous to surgery, an interesting aspect is that even making sure the people on the surgery table know each other by name has been proven to improve the team’s performance. This is a check needed to contrast the authority effect that surgeons may have on other staff members. It’s been proven that if members of a surgery team know each other’s names, they are more likely to speak up when they think that something is going wrong, even if for a nurse this means contradicting a surgeon. This enforced communication ultimately improves the team’s performance.

Executioners

On the flip side, checklists are also used in prisons to make sure that they execute prisoners according to protocol. You can read an example of an execution checklist used in Montana prisons here. The whole process is extremely curated: pre-execution checklists are to be used a month, fifteen days, a week and the day before the scheduled execution date. In addition to that, five additional checklists are to be used at various times during the execution date.

In the game Prison Architect, the player has to follow a precise checklist when having to execute an inmate. This is fundamentally a list of sequential steps, such as letting a spiritual leader talk to the death row inmate, letting the families of the murderer and of the victims in the prison, and finally taking the prisoner to the execution room. This cold and methodic procedure, as the author of the game stated in this video, has the objective of enhancing the player’s empathy towards the prisoner, and making him reflect about one of the most controversial topics in the prison system today.


Even rockstars use checklists

(Or, Van Halen were smarter than you might think)

When rock bands tour around the world, they provide organizers in the various venues they will play in a pamphlet containing a list of requests for the setting and things that must be in the backstage area. These are effectively checklists that the people preparing the stage have to follow, in order to comply with the contract they stipulated with the band. Since the show business is synonym with excess, there’s plenty of absurd requests that musicians can make, and have made. This article on Vice contains some of these.

The interesting part of this story comes when we consider those who first originated this custom, namely the Van Halen rock band. Legend has it that their checklist for venues contained a request for several bowls of M&M’s, with all the brown ones removed. For years this has been deemed as rockstar eccentricity, but then David Lee Roth, the band’s singer, stepped up to explain the whole story. It turns out that Van Halen used this specific, absurd checklist item to test whether the venue organizer had read and complied with the contract completely. Listen to the band’s frontman explain it in this video:


Conclusions

(Or, final takeaways)

We’ve seen that checklists are used by musicians, surgeons, executioners and plane pilots alike, and we now have an idea of the reasons behind their existence. We’ve tried to define them, and find out what really is important in a checklist. Now, it’s time to wrap up this article. What follows is the list of the “real” takeaways: this is what surfaces from the examples we’ve seen. This is what actually matters.

First of all, checklists are most effective when used for:

  1. New and unfamiliar tasks. These need to get done as precisely as possible, and there’s no room for error. The typical example is when there are failures in planes: it’s impossible to prepare pilots for every possible combination of things that could go wrong while flying, so we give them checklists instead. These make sure that the most important actions during an emergency are performed correctly, and act as an antidote against the pilot panic.
  2. Familiar tasks that have become routine and the doer’s attention and care start to vanish. That is when errors become more and more frequent: think of the surgeon that, for the 1000th time has to perform the same, boring operation. He’s sure he could perform it while blindfolded. He’s convinced he can’t fail. That’s when errors start popping up.

Ultimately, checklists are one of the best tools we can use when dealing with complex systems and actions. Like an airplane that’s “too much for one man to fly”, some systems and processes are just too involved. There are too many variables, too many things that could go wrong. It’s easy to forget some components of the system, or to perform an action that will yield unforeseen consequences. In these cases, it’s best to rely on certainty, and this certainty can be found in checklists.

Another key concept is that checklists are not sexy, but they always improve performance. There’s nothing exciting about a checklist. This is why they are made as simple and as effortless to use as possible. For them to be effective, one has to consciously use checklists. It’s no use to skim it quickly and consider it done. Checklists are a classic example of a step you would skip only to regret it after a while. The payoff is worth it, though: when used correctly, checklists always improve performance. There’s no way that a thoughtfully compiled checklist, condensing the result of various errors and consisting exclusively of lessons learned could in any way damage the quality of your work.

Since this is a powerful tool that can be applied to lots of different scenarios in your everyday life, in the next post we will take a look at how you can implement checklist in your own productivity process. We’ll make further distinctions between different kinds of checklists, and take a good look at the best practices when creating your own. We’ll also get to use the meta-est thing ever: a checklist for checklists.

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Additional resources

(Or, more interesting stuff that didn't make the article)

Here are some more uses for checklists:

More aviation checklist examples include:

  • The Preflight Planning Dispatch Checklist is a checklist used to ensure pilots are in optimal condition to fly.
  • You can find a Cessna checklist here.
  • Cockpit Conversation, an article published in Life, 24 August 1942, reports the dialogue between two pilots going through a checklist in a Flying Fortress.
  • Checklists for spaceships are even shown in the movie Gravity:

Originally published at www.magr.in.

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