The Checklist Manifesto (21 page)

I asked Cook how much interest others have had in what he has been doing these past two years. Zero, he said—or actually that’s not quite true. People have been intensely interested in what he’s been buying and how, but the minute the word
checklist
comes out of his mouth, they disappear. Even in his own firm, he’s found it a hard sell.

“I got pushback from everyone. It took my guys months to finally see the value,” he said. To this day, his partners still don’t all go along with his approach and don’t use the checklist in their decisions when he’s not involved.

“I find it amazing other investors have not even bothered to try,” he said. “Some have asked. None have done it.”

The resistance is perhaps an inevitable response. Some years ago, Geoff Smart, a Ph.D. psychologist who was then at Claremont Graduate University, conducted a revealing research project. He studied fifty-one venture capitalists, people who make gutsy, high-risk, multimillion-dollar investments in unproven start-up companies. Their work is quite unlike that of money managers like Pabrai and Cook and Spier, who invest in established companies with track records and public financial statements one can analyze. Venture capitalists bet on wild-eyed, greasy-haired, underaged entrepreneurs pitching ideas that might be little more than scribbles on a sheet of paper or a clunky prototype that barely works. But that’s how Google and Apple started out, and the desperate belief of venture capitalists is that they can find the next equivalent and own it.

Smart specifically studied how such people made their most difficult decision in judging whether to give an entrepreneur
money or not. You would think that this would be whether the entrepreneur’s idea is actually a good one. But finding a good idea is apparently not all that hard. Finding an entrepreneur who can execute a good idea is a different matter entirely. One needs a person who can take an idea from proposal to reality, work the long hours, build a team, handle the pressures and setbacks, manage technical and people problems alike, and stick with the effort for years on end without getting distracted or going insane. Such people are rare and extremely hard to spot.

Smart identified half a dozen different ways the venture capitalists he studied decided whether they’d found such a person. These were styles of thinking, really. He called one type of investor the “Art Critics.” They assessed entrepreneurs almost at a glance, the way an art critic can assess the quality of a painting—intuitively and based on long experience. “Sponges” took more time gathering information about their targets, soaking up what ever they could from interviews, on-site visits, references, and the like. Then they went with what ever their guts told them. As one such investor told Smart, he did “due diligence by mucking around.”

The “Prosecutors” interrogated entrepreneurs aggressively, testing them with challenging questions about their knowledge and how they would handle random hypothetical situations. “Suitors” focused more on wooing people than on evaluating them. “Terminators” saw the whole effort as doomed to failure and skipped the evaluation part. They simply bought what they thought were the best ideas, fired entrepreneurs they found to be incompetent, and hired replacements.

Then there were the investors Smart called the “Airline Captains.” They took a methodical, checklist-driven approach to
their task. Studying past mistakes and lessons from others in the field, they built formal checks into their process. They forced themselves to be disciplined and not to skip steps, even when they found someone they “knew” intuitively was a real prospect.

Smart next tracked the venture capitalists’ success over time. There was no question which style was most effective—and by now you should be able to guess which one. It was the Airline Captain, hands down. Those taking the checklist-driven approach had a 10 percent likelihood of later having to fire senior management for incompetence or concluding that their original evaluation was inaccurate. The others had at least a 50 percent likelihood.

The results showed up in their bottom lines, too. The Airline Captains had a median 80 percent return on the investments studied, the others 35 percent or less. Those with other styles were not failures by any stretch—experience does count for something. But those who added checklists to their experience proved substantially more successful.

The most interesting discovery was that, despite the disadvantages, most investors were either Art Critics or Sponges—intuitive decision makers instead of systematic analysts. Only one in eight took the Airline Captain approach. Now, maybe the others didn’t know about the Airline Captain approach. But even knowing seems to make little difference. Smart published his findings more than a decade ago. He has since gone on to explain them in a best-selling business book on hiring called
Who
. But when I asked him, now that the knowledge is out, whether the proportion of major investors taking the more orderly, checklist-driven approach has increased substantially, he could only report, “No. It’s the same.”

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.

Maybe our idea of heroism needs updating.

On January 14, 2009, WHO’s safe surgery checklist was made public. As it happened, the very next day, US Airways Flight 1549 took off from La Guardia Airport in New York City with 155 people on board, struck a large flock of Canadian geese over Manhattan, lost both engines, and famously crash-landed in the icy Hudson River. The fact that not a single life was lost led the press to christen the incident the “miracle on the Hudson.” A National Transportation Safety Board official said the flight “has to go down as the most successful ditching in aviation history.” Fifty-seven-year-old Captain Chesley B. “Sully” Sullenberger III, a former air force pilot with twenty thousand hours of flight experience, was hailed the world over.

“Quiet Air Hero Is Captain America,” shouted the
New York Post
headline. ABC News called him the “Hudson River hero.” The German papers hailed “Der Held von New York,” the French “Le Nouveau Héros de l’Amérique,” the Spanish-language press “El Héroe de Nueva York.” President George W. Bush phoned Sullenberger to thank him personally, and President-elect Barack
Obama invited him and his family to attend his inauguration five days later. Photographers tore up the lawn of his Danville, California, home trying to get a glimpse of his wife and teenage children. He was greeted with a hometown parade and a $3 million book deal.

But as the details trickled out about the procedures and checklists that were involved, the fly-by-wire computer system that helped control the glide down to the water, the copilot who shared flight responsibilities, the cabin crew who handled the remarkably swift evacuation, we the public started to become uncertain about exactly who the hero here was. As Sullenberger kept saying over and over from the first of his interviews afterward, “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.

Aw, that’s just the modesty of the quiet hero, we finally insisted. The next month, when the whole crew of five—not just Sullenberger—was brought out to receive the keys to New York City, for “exclusive” interviews on every network, and for a standing ovation by an audience of seventy thousand at the Super Bowl in Tampa Bay, you could see the press had already determined how to play this. They didn’t want to talk about teamwork and procedure. They wanted to talk about Sully using his experience flying gliders as an Air Force Academy cadet.

“That was so long ago,” Sullenberger said, “and those gliders are so different from a modern jet airliner. I think the transfer of experience was not large.”

It was as if we simply could not process the full reality of what had been required to save the people on that plane.

The aircraft was a European-built Airbus A320 with two jet engines, one on each wing. The plane took off at 3:25 p.m. on a cold but clear afternoon, headed for Charlotte, North Carolina, with First Officer Jeffrey Skiles at the controls and Sullenberger serving as the pilot not flying. The first thing to note is that the two had never flown together before that trip. Both were tremendously experienced. Skiles had nearly as many flight hours as Sullenberger and had been a longtime Boeing 737 captain until downsizing had forced him into the right-hand seat and retraining to fly A320s. This much experience may sound like a good thing, but it isn’t necessarily. Imagine two experienced but unacquainted lawyers meeting to handle your case on your opening day in court. Or imagine two top basketball coaches who are complete strangers stepping onto the parquet to lead a team in a championship game. Things could go fine, but it is more likely that they will go badly.

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.

I don’t think we recognize how easy it would have been for Sullenberger and Skiles to have blown off those preparations, to
have cut corners that day. 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. The routine can seem pointless most of the time. Not once had any of them been in an airplane accident. They fully expected to complete their careers without experiencing one, either. They considered the odds of anything going wrong extremely low, far lower than we do in medicine or investment or legal practice or other fields. But they ran through their checks anyway.

It need not have been this way. As recently as the 1970s, some airline pilots remained notoriously bluff about their preparations, however carefully designed. “I’ve never had a problem,” they would say. Or “Let’s get going. Everything’s fine.” Or “I’m the captain. This is my ship. And you’re wasting my time.” Consider, for example, the infamous 1977 Tenerife disaster. It was the deadliest accident in aviation history. Two Boeing 747 airliners collided at high speed in fog on a Canary Islands runway, killing 583 people on board. The captain on one of the planes, a KLM flight, had misunderstood air traffic control instructions conveying that he was
not
cleared for takeoff on the runway—and disregarded the second officer, who recognized that the instructions were unclear. There was in fact a Pan American flight taking off in the opposite direction on the same runway.

“Is he not cleared, that Pan American?” the second officer said to the captain.

“Oh yes,” the captain insisted, and continued onto the runway.

The captain was wrong. The second officer sensed it. But they were not prepared for this moment. They had not taken the steps
to make themselves a team. As a result, the second officer never believed he had the permission, let alone the duty, to halt the captain and clear up the confusion. Instead the captain was allowed to plow ahead and kill them all.

The fear people have about the idea of adherence to protocol is rigidity. They imagine mindless automatons, heads down in a checklist, incapable of looking out their windshield and coping with the real world in front of them. But what you find, when a checklist is well made, is exactly the opposite. 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?).

Here are the details of one of the sharpest checklists I’ve seen, a checklist for engine failure during flight in a single-engine Cessna airplane—the US Airways situation, only with a solo pi -lot. It is slimmed down to six key steps not to miss for restarting the engine, steps like making sure the fuel shutoff valve is in the OPEN position and putting the backup fuel pump switch ON. But step one on the list is the most fascinating. It is simply: FLY THE AIRPLANE. Because pilots sometimes become so desperate trying to restart their engine, so crushed by the cognitive overload of thinking through what could have gone wrong, they forget this most basic task. FLY THE AIRPLANE. This isn’t rigidity. This is making sure everyone has their best shot at survival.

About ninety seconds after takeoff, US Airways Flight 1549 was climbing up through three thousand feet when it crossed the
path of the geese. The plane came upon the geese so suddenly Sullenberger’s immediate reaction was to duck. The sound of the birds hitting the windshield and the engines was loud enough to be heard on the cockpit voice recorder. As news reports later pointed out, planes have hit hundreds of thousands of birds without incident. But dual bird strikes are rare. And, in any case, jet engines are made to handle most birds, more or less liquefying them. Canadian geese, however, are larger than most birds, often ten pounds and up, and no engine can handle them. Jet engines are designed instead to shut down after ingesting one, without exploding or sending metal shrapnel into the wings or the passengers on board. That’s precisely what the A320’s engines did when they were hit with the rarest of rare situations—at least three geese in the two engines. They immediately lost power.