The Checklist Manifesto: How to Get Things Right

But now the problem we face is ineptitude, or maybe it’s “eptitude”—making sure we apply the knowledge we have consistently and correctly.

Even the most expert among us can gain from searching out the patterns of mistakes and failures and putting a few checks in place.

In the absence of a true Master Builder—a supreme, all-knowing expert with command of all existing knowledge—autonomy is a disaster. It produces only a cacophony of incompatible decisions and overlooked errors. You get a building that doesn’t stand up straight.

That routine requires balancing a number of virtues: freedom and discipline, craft and protocol, specialized ability and group collaboration. And for checklists to help achieve that balance, they have to take two almost opposing forms. They supply a set of checks to ensure the stupid but critical stuff is not overlooked, and they supply another set

The knowledge exists. But however supremely specialized and trained we may have become, steps are still missed. Mistakes are still made.

When you’re making a checklist, Boorman explained, you have a number of key decisions. You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist.

No, the more familiar and widely dangerous issue is a kind of silent disengagement, the consequence of specialized technicians sticking narrowly to their domains. “That’s not my problem” is possibly the worst thing people can think, whether they are starting an operation, taxiing an airplane full of passengers down a runway, or building a thousand-

The question they sought to answer was why we fail at what we set out to do in the world.

You must define a clear pause point at which the checklist is supposed to be used (unless the moment is obvious, like when a warning light goes on or an engine fails). You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist.