1. The Checklist Manifesto
Why We Fail
Ignorance vs. Ineptitude
Ignorance - We don’t know everything. We are still discovering knowledge.
Ineptitude - We do not apply knowledge consistently or correctly.
The Challenge - Mastery of complexity and large amounts of knowledge.
Avoidable failures are common and persistent, not to mention demoralizing and
frustrating.
October 30, 1935 The Boeing Company demonstration flight for US Army crashed on
takeoff. The plane could carry 5X as many bombs, fly 2X farther and faster than the
competitor’s plane, but it was said, “It was too much airplane for man to fly”. The
Army chose the competitors plane and Boeing nearly went bankrupt. Boeing
response was to “invent the checklist”. Subsequent to flying the plane using
checklists their model flew 1.8 million miles without incident. The Army bought
13,000 B-17 over it’s life cycle.
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 first realized. They provide a kind of cognitive net.
They catch mental flaws inherent in all of us – flaws of memory and attention and
thoroughness.
Three kinds of problems in the world:
1. Simple problems – baking a cake from a mix.
2. Complicated problems – sending a rocket to the moon.
3. Complex problems – raising a child.
“Forcing Functions”: relatively straightforward solutions that force necessary
behavior, like checklists.
There are good and bad checklists.
Bad checklists – are vague and imprecise. Too long, hard to use and impractable.
Written by people without awareness of the situation in which they will be used.
Treat people using them as dumb and try to spell out every step in excruciating
detail. They turn people’s brains off rather than turn them on.

2. Good checklists – precise. Efficient and to the point. Easy to use even in the most
difficult situation. They do not spell everything out. A checklist can not fly a plane.
They provide reminders of the most critical and important steps – the ones that
even the highly skilled professionals using them could miss. They are practable.
By themselves, however, checklists can not make anyone follow them. Pilots use
them for two reasons: they are trained to do so, and they work!
Why are checklists difficult to adopt? Pride. Some are offended (Dr’s) by the
suggestion that they need checklists.
Checklists are not comprehensive how-to guides, they are quick and simple tools
aimed to buttress the skills of expert professionals.
Checklists improve outcomes with no increase in skill.
Professionalism Code of Conduct
1. Expectation of selflessness. We put the needs and concerns of those who
depend on us above our own.
2. Expectation of skill. We aim for excellence in our knowledge and expertise.
3. Expectation of trustworthiness. We will be responsible in our personal
behavior toward our charges.
4. Discipline. Following prudent procedure, and, in functioning with
workmates.
Discipline is hard, harder then the first three. We are by nature flawed and
inconstant creatures. We are not built for discipline. We are built for novelty and
excitement, not for careful attention to detail. Discipline is something we have to
work at.
Optimizing parts of a system is not a route to system excellence.
From the book, The Checklist Manifesto by Dr. Atul Gawande