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In Praise of Checklists or Why We Can Only Do Big Things When We Have the Little Things in Order

At the beginning of the 90s, my wife tried to cure my forgetfulness. By the front door of our apartment, she put up a list of things to check before leaving: keys, wallet, tram pass, floppy disk with my articles … Next to it, there was a string with a ballpoint pen and I had to make a check mark every day. Sounds funny right? However, the truth is that for as long as the list hung there, I didn’t forget to take any of these things.

Boeing XB-17 Boeing XB-17, model 299, pictured above preparing for its fateful first flight in 1935. Major Ployer Peter Hill at the time had forgotten to release the gust control locks. Credit: US Air Force

I had already closed my eyes, when the stewardess lightly tapped me on my shoulder. This was ten, maybe fifteen minutes, before we had taken off. “You’re sitting by an emergency exit, sir. I have to ask, are you willing to open the emergency exit if necessary and help the other passengers?”

“Of course,” I nodded. Due being two-meters tall, I almost always exclusively sit by an emergency exit when I fly.

I have no idea how many times I’ve heard this question. Definitely more than a hundred times. Regardless of the fact that in most of these cases, I had already “clicked” that I would when I bought the ticket online.

I’ve heard the warning more than a hundred times, that “in the extremely unlikely event of a drop in the cabin pressure” an oxygen mask will drop in front of my face and I should secure my mask before going to help anyone else, such as children. That I should switch off all electronic devices or put them on flight mode and that the cabin lights will be dimmed during takeoff and landing, because it is a “standard safety procedure.”

I’ve watched how to fasten and tighten the seatbelt more than a hundred times, and just as often as I’ve heard the English sentence “Cabin crew, take your seats”, which is said by the captain or pilot just before takeoff. That is, a few seconds before the engines start and the plane pulls away from the gate, so that it can climb majestically and with a gentle rocking motion up into the sky.

At that moment, I can feel my heart pounding. I’m always afraid, even though I fly on average once or sometimes twice a month. But it is an irrational fear that I can hardly do anything about.

I say irrational because these days flying is about the safest way to travel. Last year, there wasn’t even a single fatal accident in the world on the major airlines that carry nearly 3.5 billion passengers. No American airline has suffered a fatal accident since 2009.

Sure, even as I am writing down these lines, an accident could be happening. It is not out of the question. We’re talking about an industry where you can never rule out human error, terrorist acts, or technical failure. But the likelihood of it happening at the moment is at a record low.

In short, regardless of what our instincts are telling us during takeoff, landing or turbulence, we are rarely as safe as when we are onboard an airplane. This is true even if an unexpected serious health problem were to strike us. According to one study, we have a better chance of surviving this on a plane than if it happens in a car, on a train or on a bus. All this, despite the fact that we are perhaps ten kilometers above the earth.

Why is flying so safe? How can this be when the number of passengers being carried is going up– an eightfold increase over the last forty years – air fares are falling, and air travel is getting larger and more affordable than ever before? This can partly be explained by technological progress, but it is really only part of the story.

New technologies have become available in all industries, but only air travel holds such a phenomenally good score. The real reason is that it has succeeded in enforcing strict and internationally recognized regulations. That practically everything in this field takes place according to sets of binding, repetitive procedures. And this applies also to us passengers, just as I described and how we all know it to be.

It practically doesn’t matter which country you are from or with which airline you fly. Before takeoff, you always learn how to fasten your seat belt and, if part of the route goes over the sea, where you can find a life jacket.

Sometimes they’re in a hurry, for example, when the pilots need to catch a time slot for departure. And it’s about money, often a lot of money. Can you imagine a flight attendant saying to the passengers: “Today we going to skip the talk about safety, you certainly don’t want to be late, right? If you don’t know where the emergency exits are, look at the brochure in the seat pocket in front of you. And fasten your seat belts quickly because we’re taking off in two minutes.”

But this isn’t going to happen. Failure to comply with procedures is not only punishable through severe sanctions, but is treated as a criminal act. Even if this is about procedures that may seem unnecessary to us or perhaps none of the passengers are paying attention to the safety instructions before departure. No airline company or its employees is willing to risk paying the price for violating these rules.

The Best Plane and the Best Pilot

The way to excellence is through practice. To put it simply: when you do something often and on a regular basis, you start to be good at it.

If you write a few pages of text each day and you are not completely incapable, you will learn how to write well. Better than the editor-in-chief.

If you drive your car thousands of miles a month, you will become an excellent driver. Better than the designer of your car.

If you are a doctor and repeatedly perform some type of operation, you will be able to offer your patients a better chance at a full recovery than a professor who only lectures and writes about the procedure. In short, you can become a whizz in your field. It’s really something to be such a person, someone that is so damn good at something and knows this about himself or herself. Their self-confidence is justified. However, this could be, we must admit, a little dangerous.

Even if someone is a whizz, he or she can make a mistake. Not from inexperience, but paradoxically because they have so much experience with being in control. Take Major Ployer Peter Hill. In the 1930s he was probably the most experienced test pilot in the US Air Force. He had a university degree from a prestigious university, which at that time was not common among pilots, and he had flown for thousands of hours.

Hill was the brightest star among the American pilots. And at the same time, he was nice, modest and fun to be around. He loved flying, which counts in this business, and he did it well. When the US Air Force was about to formally decide in October 1935 on the supplier of a new type of bomber, Hill sat down behind a plane made by Boeing called the Model 299.

Other aircraft were presented that day by Douglas and Martin, but it seemed to be clear beforehand that Boeing would win. The plane that would come to be called by journalists as the Flying Fortress was impressive and, according to its technical parameters, in a class of its own, simply better than the competition. Hands down.

It was the best plane and the best pilot. Still, the machine crashed to the ground a few seconds after taking off. Two of the crew members perished, including the pilot, Ployer Peter Hill. Nobody could make any sense of it. The army announced the Douglas plane as the winner.

The cause of the accident was neither a technical malfunction nor a pilot’s error in the air. Major Hill was an excellent aviator with a god given talent, it was said. But he made a mistake before starting. He forgot to release the gust control locks. It wasn’t that he didn’t know that he was supposed to do it. He just forgot. Perhaps he was nervous about the demonstration flight in front of such an audience. Maybe he was already such a big shot that he didn’t focus on details. And he was not used to so many operations before the start.

The Introduction of Checklists

The Boeing bomber was truly a new-generation of aircraft. All of its parameters were better, including safety. But at the same time, it was disproportionately difficult to control. Not while in flight, there all the experienced instincts of experienced pilots could be used, but before taking off. The number of operations required before take-off had multiplied many times over.

The verdict from experts and the general public was unambiguous. Boeing had just made an airplane that very well may be technically top-notch, but it was very difficult to control. This happens sometimes. If you want things to be perfect, they become complicated. “This is not the way to do it,” everyone was suddenly saying.

Well, almost everyone. Fortunately. The army eventually bought several of the bombers from Boeing. It had such great parameters! And the experts were thinking about how the machine could become safe to fly. Would it help to train pilots more? Probably not, considering that Major Hill was one of the most experienced and highly trained pilots. So then, what should be done?

Thankfully, the idea came to them. Actually, it was a little thing that helped. The checklist as a list of what needs to be done at the moment. If the accident hadn’t happened, it might not even have been successful. Whizzes and big shots like Major Hill would have felt offended by it. He had learned to fly like a god, only to have someone tell them they want to see if there is fuel is in the tank before the flight? What an insult!

But whenever someone has ten and more tasks to keep track of, they can easily forget one. That’s exactly what happened. After the accident, the US Army introduced checklists. It saved Boeing, which eventually sold thirteen thousand B-17 bombers, which became one of the most famous pieces of military aircraft of all time.

But its significance doesn’t stop there. It is more than possible that the introduction of checklists into aviation – for all kinds of activities, including passenger safety instructions – is what has made this mode of transportation so safe.

Don’t forget your keys, wallet …

These so-called checklists, are simple, and that’s why they are an ingenious invention. They make sense when dealing with complex, sophisticated activities.

In a driving school, we learn that before each trip we should go around the vehicle and check to see if everything looks right. Whether the tires are inflated, if oil or gasoline could be leaking out of the car. At night, we should check if all the lights are lit. But I don’t know anyone – except one of the characters in the movie Run, Waiter, Run! – who actually does it. And it’s hard to say if they did this whether it would improve road safety. It certainly couldn’t hurt.

I remember how in the early 90s my wife tried to cure my forgetfulness. Partially as an aspect of our honeymoon teasing and partially in earnest she put up a list by the front door of our apartment of things to check before leaving: keys, wallet, tram pass, floppy disk with my articles (If any millennials need an explanation about what a floppy disk is, I can tell you upon request). Next to it, there was a string with a ballpoint pen and I had to make a check mark every day. Sound funny, right? But the truth is that for as long as the list hung there, I didn’t forget to take any of these things.

In addition to aviation, checklists were also introduced in medicine where “big shot doctors” are just as tough a nut to crack as pilots. But there are studies that have found that lists for even the most basic acts for all kinds of medical activities have saved hundreds of thousands of lives. Again: it’s nothing against the expertise of the doctors. In fact, it has nothing to do with it. Rather, it’s human nature that tends to lead us to underestimate seemingly self-evident and simple activities. Or to overlook them by relying on our own “amazingness.”

And as I am writing this and looking for the point of this ode to the checklist, what comes to my mind is the way in which the procedures are a nice metaphor for the institutions in a democracy. It doesn’t matter how much politicians gain from winning the voters’ favor, how much they might be natural talents for this, or how big a deal they are, at the end of the day they also have to follow “checklists”: they must be subject to strong and stable institutions. For it is this that distinguishes strong democracies – even if crackpots are able to win elections from time to time in them – from those countries that have an uncertain future.

Praise be to Checklists!

Translated by Scott Hudson from the original article published in Czech on February 9, 2018 by Hospodarske noviny.

Milos Cermak, May 23, 2018

writer and editor-in-chief of Hospodarske noviny online — the major Czech newspaper owned by the Economia media house

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