The Checklist Manifesto: How to Get Things Right

by Atul Gawande

We don’t like checklists. They can be painstaking. They’re not much fun. But I don’t think the issue here is mere laziness. There’s something deeper, more visceral going on when people walk away not only from saving lives but from making money. It somehow feels beneath us to use a checklist, an embarrassment. It runs counter to deeply held beliefs about how the truly great among us—those we aspire to be—handle situations of high stakes and complexity. The truly great are daring. They improvise. They do not have protocols and checklists.

“I want to correct the record right now. This was a crew effort.” The outcome, he said, was the result of teamwork and adherence to procedure as much as of any individual skill he may have had.

Before the Pilots started the plane’s engines at the gate, however, they adhered to a strict discipline—the kind most other professions avoid. They ran through

their checklists. They made sure they’d 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. And by adhering to this discipline—by taking just those few short minutes—they not only made sure the plane was fit to travel but also transformed themselves from individuals into a team, one systematically prepared to handle what ever came their way.

The checklist gets the dumb stuff out of the way, the routines your brain shouldn’t have to occupy itself with (Are the elevator controls set? Did the patient get her antibiotics on time? Did the managers sell all their shares? Is everyone on the same page here?), and lets it rise above to focus on the hard stuff (Where should we land?).

Once that happened, Sullenberger made two key decisions: first, to take over flying the airplane from his

copilot, Skiles, and, second, to land in the Hudson. Both seemed clear choices at the time and were made almost instinctively. Within a minute it became apparent that the plane had too little speed to make it to La Guardia or to the runway in Teterboro, New Jersey, offered by air traffic control. As for taking over the piloting, both he and Skiles had de cades of flight experience, but Sullenberger had logged far more hours flying the A320. All the key landmarks to avoid hitting—Manhattan’s skyscrapers, the George Washington Bridge—were out his left-side window. And Skiles had also just completed A320 emergency training and was more recently familiar with the checklists they would need.

airplanes, they are as integral to a successful flight as anesthesiologists are to a successful operation.

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

and something they found difficult to replicate in simulation.

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. They understood how to function in a complex and dire situation. They recognized that it required teamwork and preparation and that it required them long before the situation became complex and dire.

First is an expectation of selflessness: that we who accept responsibility for others—whether we are doctors, lawyers, teachers, public authorities, soldiers, or pilots—will place the needs and concerns of those who depend on us above our own. Second is an expectation of skill: that we will aim for excellence in our knowledge and expertise. Third is an expectation of trustworthiness: that we will be responsible in our personal behavior toward our charges.

Aviators, however, add a fourth expectation, discipline: discipline in following prudent procedure and in functioning with others. This is a concept almost

entirely outside the lexicon of most professions, including my own. In medicine, we hold up “autonomy” as a professional lodestar, a principle that stands in direct opposition to discipline. But in a world in which success now requires large enterprises, teams of clinicians, high-risk technologies, and knowledge that outstrips any one person’s abilities, individual autonomy hardly seems the ideal we should aim for. It has the ring more of protectionism than of excellence. The closest our professional codes come to articulating the goal is an ...

Discipline is hard—harder than trustworthiness and skill and perhaps even than selflessness. We are by nature flawed and inconstant creatures. We can’t even keep fro...

discipline. We are built for novelty and excitement, not for careful attention to detail. Discipline is...

The preflight checklist began as an invention of a handful of army Pilots in the 1930s, but the power of their discovery gave birth to entire organizations. In the United States, we now have the National Transportation Safety Board to study accidents—to independently determine the underlying causes and recommend how to remedy them. And we have national regulations to ensure that those recommendations are incorporated into usable checklists and reliably adopted in ways that actually reduce harm.