Thursday, February 18, 2010


I've been reading a very interesting book called "The Checklist Manifesto - How to Get Things Right" by surgeon Atul Gawande. Already I can hear you say, "Then what is an airplane doing at the top of your blog?" Gawande has a most interesting illustration in his book of the emergence of the checklist in aviation, and I was so taken by it I thought I'd share it with you.

Gawande writes that on October 30, 1935 at Wright Air Field in Dayton, Ohio, the U.S. Army Air Corps held a flight competition for airplane manufacturers vying to build the military's next-generation long-range bombers. Boeing was thought to be the front runner in the contest. They had built a plane that could fly faster and held five times as many bombs than the army requested. It was called the Model 299 test plane and piloting it was the air corps' chief of flight testing.

"A small crowd of army brass and manufacturing executives watched as the Model 299 test plane taxied onto the runway. It was sleek and impresive, with a 103-foot wingspan and four engines jutting out from the wings, rather than the usual two. The plane roared down the tarmac, lifted off smoothly and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill."

An investigation into the crash revealed there was no mechanical error but the crash was due to "pilot error." The report indicated that because the plane was substantially more complex than previous aircraft, the new plane required the pilot to attend to so many new controls and mechanisms that it was just impossible to get them done. The newspapers opined that it was just too much airplane for one man to fly. Douglas's smaller design was declared the winner, and Boeing nearly went bankrupt.

But Boeing believed in their plane. The Army bought a few, got their test pilots together and figured out that more pilot training was not called for. After all, Hill had been the best. But what they decided was that a simple checklist for takeoff should be developed. There was too much to do to depend on someone's memory to accomplish it. Their checklist was simple, brief, short enough to fit on an index card, with step-by-step checks for takeoff, flight, landing and taxing. The pilots knew how to do all that stuff. The checklist simply made them make sure they hadn't forgotten anything.

The test pilots began using the checklist, and the pilots went on to fly the Model 299 a total of 1.8 million miles without one accident.

The Army ordered 13,000 of them, which it dubbed the B-17. And it was because of this plane, and the development of a checklist, that the army gained a decisive air advantage in the Second World War, enabling its devastating bombing campaign across Nazi Germany.

Less than 10 years after the crash of that first Boeing plane, my Uncle Bert Ryland stepped into the cockpit of his B-17 and joined those flights over Germany. I have written about his career in an earlier blog.

Why I post this today is that I learned something in this book by a surgeon about my uncle, an amazing thing to happen. Who would have thought? I also learned of some exceptionally interesting facts about surgeries, hospitals, the World Health Organization, and believe it or not, about building skyscrapers. The common denominator is the "Checklist." I'm not through with the book yet, and who knows what other surprises I'll find. But probaby none quite as amazing as about the B-17.

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