How not to forget: Use Checklists

In 2006, I had a trip to Israel, Jordan and Egypt.  Because my work life then was toxic, I ended packing the same morning as our departure.   I was about to leave for the airport when I thought of checking my stash of leftover bills from past trips just in case I had any US dollars I could bring.  When I checked the pouch where I store them, my passport was still there!   In short, if I didn't look for leftover bills, I would have totally forgotten my passport!  Yikes!  

My 2 biggest learnings from that incident were (1) always have a travel checklist, and (2) never pack hours before a trip!  

It's been 11 years since I started using checklists because of that incident.  I have checklists for check-in luggage, for hand-carry, for a beach destination, etc.  Fortunately, I've never had any close encounter of missing a flight due to a forgotten passport.  Whew!

Through the years, my use of checklists has expanded.  I even have checklists if I'm going to a pilates class, or going swimming, a checklist for weekly and monthly household chores, name it!   Wahaha…. And it works because it saves you a lot of time (no need to rack your brain on what to bring every time!) and it gives you peace of mind knowing that the essential things you need to do or bring have been already pre-identified.  

Because I love to use checklists, when I learned that Atul Gawande, the author of one of my favorite books (Being Mortal) had a book entitled "Checklist Manifesto:  How to Get Things Right", I knew I had to read it.   And I was blown away by what I learned from the book - how checklists are used in hospitals, construction sites, airlines, etc. to save lives.  My checklists looked nonsense and immaterial!  Wahaha….

The book cites that one of the reasons why we make mistakes is because of ineptitude, the opposite of which is eptitude.  But the challenge is - how do we apply our eptitude or the knowledge that we have consistently and correctly?  The simple solution is to have a checklist.

For example, a doctor like Gawande on a given ordinary day, could have 6 patients with 6 completely different primary medical problems and a total of 26 different additional diagnoses.  He said no matter how specialized and trained doctors are, steps could still be missed and mistakes made.  And that's where checklists come in.

In the field of medicine, it was a doctor named Pronovost who first introduced the use of checklists.  He plotted out the steps to take in order to avoid infections when putting in a central line. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with antiseptic, (3) put sterile drapes over the entire patient, (4) wear a mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion site once the line is in.  Nurses are authorized to stop doctors if they saw them skipping a step on the checklist.  

What were the results of using this checklist after 1 year in a test hospital?  The ten-day line-infection rate went from 11 percent to zero!  Yep, zero! Amazing, right?!   

Pronovost's team continued to use the checklist and monitor the results for 15 more months.  The results?  Only 2 line infections occurred during the entire period. They calculated that, in that one hospital, the checklist had prevented 43 infections and 8 deaths, and saved USD2Million in costs.  Wow.   

  

Another field that heavily uses checklists is the airlines industry.  There was this Boeing plane (Model 299) which could carry lots of bombs, fly faster and fly twice the distance vs previous bombers.  But when the first plane was first flown by the military, it lifted off smoothly but shortly after, it exploded.   The cause of the explosion was due to pilot error.   How could that have happened?  The new plane required the pilot to attend to 4 engines, each with its own oil-fuel mix, retractable landing gear, wing flaps, among many other things. While doing all of these, the pilot (though a highly experienced air force pilot), forgot to release a new locking mechanism on the elevator and rudder controls.  That single simple omission caused the explosion.  One  newspaper concluded that the plane was “too much airplane for one man to fly.”

But what did a group of test pilots think of doing?  They created a pilot’s checklist.  Flying this new plane was too complicated to be left to the memory of any one person, however expert, they said. Their pilot checklist contained step-by-step checks for takeoff, flight, landing, and taxiing. It had the kind of stuff that all pilots know to do. Check that the brakes are released, that the instruments are set, that the door and windows are closed, that the elevator controls are unlocked— information which pilots may consider dumb stuff because it's the most basic stuff they do all the time.   But guess what?  With that checklist, the pilots went on to fly the same plane model - Model 299 - a total of 1.8 million miles without one accident!  The army ultimately ordered almost 13,000 units which they dubbed the B-17 and which were used during WW2.  

Another great example in the airlines industry was this certain incident (forgot to take note of the airlines and flight no.) when the plane's engine stopped as it was nearing its destination.  The pilot tried to rev up the engines but the plane exploded on its final approach.  After careful study on what may have caused the explosion, the best explanation which the investigators could give was that on a long, smooth polar flight, the fuel flow becomes so slow that moisture (about 2 drops per gallon) could freeze and float in the fuel as tiny ice crystals and accumulate somewhere in the fuel tank. Then, during a brief burst of acceleration, such as on the final approach, the sudden increase in fuel flow might release the accumulation, causing blockage of the fuel lines.

Even if it wasn't proven that that was the cause of the plane's explosion, the Aviation Administration in the US in 2008 decided to issue a detailed advisory on how to prevent ice from accumulating on polar flights and how to recover flight control if engine failure happens.   The advisory was very critical because the steps presented go against the basic instinct of pilots when an engine loses power. When an engine fails, a pilot's instinct is to rev the engine, but in the special case of polar flights, revving the engine would throw more ice crystals to the fuel lines.  Thus, the pilots should do the opposite - turn the engine idle momentarily to allow time for heat exchangers in the piping to melt the ice - which takes only seconds - allowing the engines to recover.  Again, this was just the investigators’ best guess but an advisory was issued anyway.

But thanks to that advisory because on November 26, 2008, the disaster almost happened again. It was a Delta Air Lines flight from Shanghai to Atlanta with 247 people aboard. The Boeing 777 was at 39,000 feet over Great Falls, Montana when its right No. 2 engine failed.   But the pilot and co-pilot knew what to do - they got out their checklist for polar flights... the engine recovered and 247 people were saved. It went so smoothly, the passengers didn’t even notice.  Wow.

A more popular example for the airlines industry is that of the US Airways Flight 1549 incident in 2009 - the flight that took off from La Guardia Airport in New York City which struck a large flock of Canada geese over Manhattan, lost both engines, famously crash-landed in the icy Hudson River and where everyone survived.

Something new I learned from the book (or which I probably read before but just forgot) was that the pilot and co-pilot of that flight have never flown together before that trip. How could they have successfully pulled that off, right? Thanks again to checklists. The co-pilots ran through their checklists before the flight and introduced themselves to each other and the cabin crew. They did a short briefing, discussing the plan for the flight, potential concerns, and how they’d handle troubles if they ran into them... Take note that the crew had more than 150 total years of flight experience—150 years of running their checklists over and over and over, practicing them in simulators, studying the annual updates. They could have easily taken for granted the checklist routine but they did not.

To refresh your memory on what happened with US Airways Flight 1549, I'm lifting off some excerpts from the book coz the story is just amazing.    For some context on how could some geese possibly caused the engine failure, jet engines are apparently made to handle most birds, liquefying them. The kind of geese that hit the engine of the plane - Canada geese - are however larger than most birds and no engine can handle them. After ingesting one, jet engines are designed to shut down without exploding and that's precisely what happened.  Except that the situation was unfortunately rare for Flight 1549 - 2 engines, not just 1 - were hit by the geese, thus, the plane immediately lost power.

Once that happened, the pilot, Sullenberger,  immediately made 2 key decisions:  first to take over flying the airplane from his co-pilot, Skiles, and second, to land in the the Hudson.  Once Sullenberger said "My aircraft," and put his hands on the controls, Skiles replied "Your aircraft".  There was no argument nor discussion between the 2 co-pilots on what to do next. The briefing they had before the flight had made them a team.  Sullenberger would look for the nearest, safest possible landing site.  Skiles would go to the engine failure checklists and see if he could relight the engines.  Except for the warning system, the cockpit was virtually silent as each pilot concentrated on his tasks and observed the other for cues that kept them coordinated.       

The plane had only 3 1/2 minutes of glide in it. In that time, Skiles needed to make sure he’d done everything possible to relight the engines while also preparing the aircraft for ditching if it wasn’t feasible. But the steps required just to restart one engine typically take more time than that. He had some choices to make. Plunging out of the sky, he judged that their best chance at survival would come from getting an engine restarted. So he decided to focus almost entirely on the engine failure checklist and running through it as fast as he could. The extent of damage to the engines was unknown, but regaining even partial power would have been sufficient to get the plane to an airport. In the end, Skiles managed to complete a restart attempt on both engines, something investigators later testified to be “very remarkable” in the time frame he had—and something they found difficult to replicate in simulation. Yet he did not ignore the ditching procedure, either. He did not have time to do everything on the checklist. But he got the distress signals sent, and he made sure the plane was properly configured for an emergency water landing.

Meanwhile, the 3 flight attendants in the cabin—Sheila Dail, Donna Dent, and Doreen Welsh—followed through on their protocols for such situations. They had the passengers put their heads down and grab their legs to brace for impact. Upon landing and seeing water through the windows, the flight attendants gave instructions to don life vests. They made sure the doors got open swiftly when the plane came to a halt, that passengers didn’t waste time grabbing for their belongings, or trap themselves by inflating life vests inside the aircraft.

Just two of the four exits were safely accessible. Nonetheless, working together they got everyone out of a potentially sinking plane in just three minutes—exactly as designed. While the evacuation got under way, Sullenberger headed back to check on the passengers and the condition of the plane. Meanwhile, Skiles remained up in the cockpit to run the evacuation checklist—making sure potential fire hazards were dealt with, for instance. Only when it was completed did he emerge. The arriving flotilla of ferries and boats proved more than sufficient to get everyone out of the water. Air in the fuel tanks, which were only partly full, kept the plane stable and afloat. Sullenberger had time for one last check of the plane. He walked the aisle to make sure no one had been forgotten, and then he exited himself.

So who was the hero here? No question, there was something miraculous about this flight. Luck played a huge role. The incident occurred in daylight, allowing the pilots to spot a safe landing site. Plenty of boats were nearby for quick rescue before hypothermia set in. The bird strike was sufficiently high to let the plane clear the George Washington Bridge. The plane was also headed downstream, with the current, instead of upstream or over the ocean, limiting damage on landing. Nonetheless, even with fortune on their side, there remained every possibility that 155 lives could have been lost that day. But what rescued them was something more exceptional, difficult, crucial, and, yes, heroic than flight ability. The crew of US Airways Flight 1549 showed an ability to adhere to vital procedures when it mattered most, to remain calm under pressure, to recognize where one needed to improvise and where one needed not to improvise. 

Amazing story, right?!  What's even more amazing was when Sullenberger, who was hailed the main hero of the flight, was interviewed said  “I want to correct the record right now. This was a crew effort.” The outcome, he explained, "was the result of teamwork and adherence to procedure as much as of any individual skill he may have had".  Wow.  You know he's really one gifted individual. 

In case you want to start designing checklists, here are some tips from the book.  
There are 2 kinds of checklists:

DO-CONFIRM checklist - this is where team members perform their jobs from memory and experience; they pause to run the checklist and confirm that everything that was supposed to be done was done.

READ-DO checklist - this is where people carry out the tasks as they check them off—it’s more like a recipe. 

And here are the characteristics of a good checklist (more applicable to procedural checklists though than my petty checklists. Wahaha...)

Good checklists are precise, efficient, to the point, and easy to use even in the most difficult situations.  They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss.   These are also known as “the killer items”—the steps that are most dangerous to skip but are sometimes overlooked. 

Good checklists are not lengthy.  A rule of thumb is to keep it to between five and nine items, which is the limit of working memory. 

Hope the stories above inspire you to start using checklists even if my kind of checklists are petty and simple. Wahaha....  At the start though, you may forget a thing or two, but that's ok.   Checklists are meant to be continuously updated and improved on.