Your Checklists will Kill You

You’re in the left seat of a Boeing 737 Max. During initial climbout, the elevator trim starts running down — hard. The cockpit lights up with red CAS warnings. You can see your nose pitching down into the ground. All of your strength on the yoke can’t prevent the attitude change. Your first officer digs out the checklists and starts reading off items. You follow line by line, and get the errant system disengaged just in time to impact terrain.

This is a radical oversimplification of the scenario that played out in the cockpits of LionAir 610 and Ethiopian 302. A long causal chain preceded these tragedies. However, there’s one central misunderstanding which directly caused the deaths of all involved: the difference between checklists and do lists. That distinction could change the way you look at your own checklists, forever.

More than Semantics

People like me have been yelling at you about checklists for years. There’s a decent book about it. Chances are there are checklists embedded in the way you do business, whether they started as top-down initiatives or grew organically on your managers’ whiteboards and sticky notes.

We’ve all done you a disservice. The very fields where checklists emerged as lifesavers: surgery and aviation, have long understood a nuance we forgot to pass on when preaching the gospel to those operating without obvious time pressure.

A “check” list is a set of items that is read after a set of actions to confirm none of those actions has been missed. A “do” list is a set of items read in order and completed one by one as the reader progresses through the list. A checklist is redundant. A do list is not.

Why is this important? You’ve been running do lists without knowing it. It’s instinctive. The default mode for everyone who gets into my cockpit and offers to run my checklists is to read the left column, expecting me to do the action and come back for my next instruction. That works fine with two calm pilots — one to read and check, the other to perform the action. But how well does it work when your head is popping back and forth from a tiny chart with small print to the flight controls that are supposed to save your life? And how well does it work when you’ve got 15 seconds to turn the MCAS off and save a 737-load of passengers?

The uncomfortable truth is that in order for checklists to be used effectively, the process owner needs to have their order of actions memorized. After flowing through those actions, they can turn their attention to the checklist, verifying that they have indeed not missed anything.

Our businesses don’t work well when every decision needs to be run up the chain. We all need to decide how many actions we’ll empower our people to flow through before getting together to check the list. We all need to understand that when the red CAS warnings start going off and the airplane pitches at the ground, a bias to action and a response centered on common sense are probabilistically superior to a delayed reaction following the letter of a policy that was written without context or color.

3 Lists to turn into Flows

The answer to the 737 MAX MCAS system failures was to de-activate the malfunctioning envelope protection software, turning the Boeing into a big Cessna. What are the big-picture goals hiding behind your checklists?

  1. Customer Service. When Tim Ferriss was building his sports nutrition brand, he found he was spending huge amounts of time dealing with escalations from his CS team. He made the decision to authorize increasing amounts of money to solve problems without his input. Tim would check these “hundred dollar decisions” in bulk — first weekly, then monthly, then quarterly as his trust in team members grew. Can you replace any of your business’ checklists and cumbersome responsibility flowcharts with simple thresholds for common-sense action?
  2. Sales. Has anything worth selling ever really been sold off a sales script? Do you have any interest in selling something whose best medium for conversion is a rigid flowchart? Do you enjoy speaking to someone who’s obviously on rails in any situation, let alone when you’re considering spending money? Instead of setting your sales scripts up as do lists, invest in your employees. Teach them the principles, teach them the product, empower instinctive answers. They can review tricky situations with their manager later, turning them into learning opportunities. Sound too idealistic? Consider what that means for your product and your confidence in your people.
  3. Pair or Check. When I worked in Dr. Hafler’s lab at MIT, I followed detailed experimental protocols which included dozens of procedures and precise ratios over a period of weeks at a time. The chances that I screwed the pooch at least once are highly non-zero. This is a big and unspoken part of why so much basic science is not able to be replicated in follow-on studies. If you have individuals in your organization following highly scripted action plans for day-to-day tactics, consider instructing them in the ways of the true checklist. Running a thumb down a do list is a recipe for skipped items. Memorizing the flow and checking it later is the dominant strategy. If the material is so precious that chucking it after a check list picks up an error is not an option, then the activity deserves to be paired — not handled solo.

Cool Thing of the Week:

BRS Camping Stove

It’s summer, which means it’s camping season. I’ve never really understood that correlation. After all, you can chop down a tree and make a fire to keep you warm. There’s no anti-fire to cool down the tent on a 90 degree buggy summer night. But I digress.

You know how sometimes the cheap stuff is the good stuff? Like Reese’s peanut butter cups, or a jug of Carlo Rossi Sangria? The BRS stove, at 17 bucks, is the lightest and most trail-tested backpacking stove in the world. It screws onto a fuel canister and boils water just as well as my fancy $50 snow peak stove — but it weighs less and packs down smaller. I won’t begrudge anyone the gucci stove. I enjoy mine, but it lives in the adventure mobile now — not my backpack. That spot is reserved for this little pocket rocket.

Get /Giphy With it:

Useful JPEG to send to colleagues:

Mandatory Self-Promotion

After years building startups in NYC, and a stint helping McKinsey & Co. develop their startup accelerator, I’m now leading the charge @ Brandt & Co., a boutique consultancy serving investors and founders in the early-stage ecosystem.

If you like the Urbach Letter, the best way to give back is emailing me copious atta-boys to print out and stick on my fridge.

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