The use of safety tools such as checklists have been highlighted in books such as the Checklist Manifesto by Atul Gawande. This book (and in an article written by the same author– sorry it is behind a paywall) describes the value of using checklists to improve safety in a variety of industries, including in healthcare. Yet, sometimes it has been difficult to convince physicians to use checklists, so I was wondering how some industries made this transitions.
Aviation is an industry that has, until recently, been remarkable safe. In general, it is far safer to get on a plane than it is to drive a long distance to your destination. The last few years related to some issues with Boeing plane design and build have made many of us feel a bit more anxious when we get on a plane. Yet, prior to this, the U.S. aviation industry has had a remarkable safety record (your bags may not have quite the same outcome 😉). Building this safety record took more than a single strategy, but certainly checklists played a role. So how did a culture such as aviation come to use a tool as simple a checklist.
The Introduction of Checklists in Aviation
The aviation industry adopted checklists as a standard operating procedure following several catastrophic accidents in the early days of aviation. These incidents began to highlight the importance of procedural adherence and human error mitigation in ensuring flight safety. Although pilots are experts in what they do, the very familiarity made it all too easy to miss critical steps in flight safety.
An early incident: The Boeing Model 299 Crash (1935)
The adoption of checklists can be traced to a pivotal event in 1935 when the prototype of the Boeing Model 299 (later the B-17 Flying Fortress) crashed during its first evaluation flight. The crash was caused by the crew’s failure to release the elevator lock before takeoff, a basic but crucial step. The Model 299 was an advanced aircraft for its time, featuring complex systems and requiring more detailed pre-flight procedures than earlier planes. The horrible event demonstrated that even the most experienced pilots could forget the most basic but critical steps in the operation of such complex machinery.
Investigators concluded that the aircraft was not “too much airplane for one man to fly,” as initially thought, but rather that its complexity necessitated a structured system to ensure all steps were completed. This led to the creation of the very first aviation checklist.
So What Did Pilots Think About This Thing Called a Checklist?:
1. Perceived Insult to Expertise – Experienced pilots viewed checklists as a challenge to their professionalism, believing they should rely on their training and instincts rather than a written procedure.
2. Resistance to Change – Pilots accustomed to less formalized procedures were reluctant to adopt a new system that seemed cumbersome or unnecessary.
3. Cultural Barriers – Aviation, at the time, had a culture of individualism and heroism. Many pilots prided themselves on their ability to handle situations independently, without external aids. They did not necessarily feel that things such as a checklist were needed.
So….How Did Checklists Became Widely Accepted By a Bunch of “Cowboys”?
1. Demonstrated Safety Benefits – As more airlines and military operations adopted checklists, the reduction in accidents due to human error became increasingly obvious. This hard data reinforced the value of checklists and helped drive broader acceptance.
2. Regulatory Mandates – Aviation authorities like the Civil Aeronautics Board (the precursor to the FAA) began mandating the use of checklists for certain operations, especially in commercial aviation, which standardized their use.
3. Integration into Training – Flight schools incorporated checklist use into training programs, emphasizing them as essential tools for safe operation rather than optional aids.
4. Normalization Through Practice – Over time, the routine use of checklists became second nature to pilots, much like any other cockpit procedure. As newer generations of pilots trained with checklists from the start, their use became normalized.
5. Evolution of Checklist Design – Early checklists were basic and sometimes unwieldy. Improvements in design made them more user-friendly, concise, and tailored to specific phases of flight, increasing their practicality.
6. Cultural Shift in Aviation – A gradual cultural shift within aviation emphasized teamwork, standardization, and safety over individualism. Checklists became a symbol of professionalism and discipline, aligning with this new ethos.
Where are we today?:
Today, checklists are a non-negotiable element of aviation operations. They are used across all phases of flight, including pre-flight, takeoff, cruise, approach, and landing. Modern checklists are integrated into electronic flight bags (EFBs) and cockpit displays, further streamlining their use.
The acceptance and integration of checklists transformed aviation safety, reducing accidents attributable to human error and setting a precedent for other industries such as healthcare, where checklists have been considered as a method to improve safety.
This transition highlights how a critical failure, combined with evidence-based solutions and regulatory enforcement, can potentially overcome resistance and existing culture to begin to drive systemic change in the way that industries view their approach to safety.