The Checklist Manifesto by Atul Gawande

Author:Atul Gawande
Language: eng
Format: epub, azw3, mobi, pdf
Publisher: Henry Holt and Co.

6. THE CHECKLIST FACTORY

Some time after that first miserable try, I did what I should have done to begin with. I went to the library and pulled out a few articles on how flight checklists are made. As great as the construction-world checklists seemed to be, they were employed in projects that routinely take months to complete. In surgery, minutes matter. The problem of time seemed a serious limitation. But aviation had this challenge, too, and somehow pilots’ checklists met it.

Among the articles I found was one by Daniel Boorman from the Boeing Company in Seattle, Washington. I gave him a call. He proved to be a veteran pilot who’d spent the last two decades developing checklists and flight deck controls for Boeing aircraft from the 747-400 forward. He’d most recently been one of the technical leaders behind the flight deck design for the new 787 Dreamliner, including its pilot controls, displays, and system of checklists. He is among the keepers of what could be called Boeing’s “flight philosophy.” When you get on a Boeing aircraft, there is a theory that governs the way your cockpit crew flies that plane—what their routines are, what they do manually, what they leave to computers, and how they should react when the unexpected occurs. Few have had more experience translating the theory into practice than Dan Boorman. He is the lineal descendant of the pilots who came up with that first checklist for the B-17 bomber three-quarters of a century ago. He has studied thousands of crashes and near crashes over the years, and he has made a science of averting human error.

I had a trip to Seattle coming up, and he was kind enough to agree to a visit. So one fall day, I drove a rental car down a long flat road on the city’s outskirts to Boeing’s headquarters. They appeared rather ordinary—a warren of low, rectangular, institutional-looking buildings that would not be out of place on the campus of an underfunded state college, except for the tarmac and hangar of airplanes behind them. Boorman came out to meet me at security. He was fifty-one, pilot-trim, in slacks and an open-collared oxford shirt—more like an engineering professor than a company man. He took me along a path of covered concrete sidewalks to Building 3-800, which was as plain and functional as it sounds. A dusty display case with yellowing pictures of guys in silver flight suits appeared not to have been touched since the 1960s. The flight test division was a fluorescent-lit space filled with dun-colored cubicles. We sat down in a windowless conference room in their midst. Piles of checklist handbooks from US Airways, Delta, United, and other airlines lay stacked against a wall.

Boorman showed me one of the handbooks. It was spiral bound, about two hundred pages long, with numerous yellow tabs. The aviation checklist had clearly evolved since the days of a single card for taxi, takeoff, and landing, and I wondered how anyone could actually use this hefty volume.

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