Every day, we take major or minor decisions in our day to day life. Some of them may be right and some of them may go wrong. We don’t know the consequence of our decisions i.e. we don’t know how it will impacts us or the people connected to us. So in order to get the odds in our favor, we need to concentrate on the right decisions making. But with human, there is a psychological and inheritance issue, most of the time we get biased whiles making decisions. We get biased towards psychological biases, what other people think, what society think, what happen if I am wrong, there are many…..
So the question is how to take the right
decision?
And the answer comes from a simple
checklist. While taking major decisions prepare a checklist with all the
possible right and wrong outcomes and then check one by one. Example- while
making an investment in stock market, you can have a checklist with question
like-
-
Have I analyzed the
industry well, without any bias?
-
Have I checked the
management properly?
-
Do I have margin of
safety at current price?
-
What if the investment
goes wrong? Will it affect me and if yes how and in how many ways?
-
Am I able to sleep
well if the invested money lost?
-
There are many
more…….
The most of the problems in life and in
investing and in any field will be solved by just a simple checklist.
If you don’t believe just read the full
post, you come to believe on checklist procedure.
Failures are common across everything from
medicine to finance to life to any industry. We should know better but we
don't. The reason we don't learn is explained better in the book TheChecklist Manifesto by Atul Gawande
“The volume and complexity of what we know has exceeded our
individual ability to deliver its benefits correctly, safely, or reliably.
Knowledge has both saved us and burdened us.”
What Atul is suggesting is the knowledge and information
consumed by us is too much and very complex, so to take the advantage of the
information and knowledge, we need to identify the definite way-Checklist
In every field from medicine to construction to aviation to
IT to entertainment, there are practical procedures, policies and best
practices. Atul has given an situation from modern medical case:
“[Y]ou have a desperately sick
patient and in order to have a chance of saving him you have to get the
knowledge right and then you have to make sure that the 178 daily tasks that
follow are done correctly—despite some monitor’s alarm going off for God knows
what reason, despite the patient in the next bed crashing, despite a nurse
poking his head around the curtain to ask whether someone could help “get this
lady’s chest open.” There is complexity upon complexity. And even
specialization has begun to seem inadequate. So what do you do?”
see the below checklist from Aviation industry-cessna 172
fuel injected checklist
In the book The Checklist Manifesto, Atul Gawande discussed that super-intelligent specialist have two
advantages over ordinary candidate: greater knowledge of the things that matter
and “a learned ability to handle the complexities of that particular job.” But
even for these super intelligent candidate, avoiding mistakes is proving
impossible.
How the concept of checklist come to the knowledge:
In the book The checklist manifesto, Atul has explained as
below-
“On October 30, 1935, at Wright Air
Field in Dayton, Ohio, the U.S. Army Air Corps held a competition for airplane
manufacturers vying to build the next-generation of the long-range bomber. Only
it wasn't supposed to be much of a competition at all. The Boeing Corporation's
gleaming aluminum-alloy Model 299 was expected to steal the show, its design
far superior to those of the competition. In other words, it was just a
formality.
As the Model 299 test plane taxied onto the runway, a small group of army brass
and manufacturing executives watched. The plane took off without a hitch. Then
suddenly, at about 300 feet, it stalled, turned on one wing, and crashed
killing two of the five crew members, including the pilot Major Hill.
Of course everyone wanted to know what had happened. An investigation revealed
that there was nothing to indicate any problems mechanically with the plane. It
was “pilot error.” The problem with the new plane, if there was one, was that
it was substantially more complex than the previous aircraft. Among other
things, there were 4 engines, each with its own fuel-mix, wing flaps, trim that
needed constant adjustment, and propellers requiring pitch adjustment. While
trying to keep up with the increased complexity, Hill had forgotten to release
a new locking mechanism on the rudder controls. The new plane was too much for
anyone to fly. The unexpected winner was the smaller designed Douglas.
Here is where it really gets interesting. The army, convinced of the technical
superiority of the plane, ordered a few anyway. If you're thinking they'd just
put the pilots through more training to fly the plane, you'd be wrong. Major
Hill, the chief of flight testing, was an experienced pilot, so longer training
was unlikely to result in improvement. Instead, they created a pilot's
checklist.
The pilots made the list simple and short. It fit on an index card with
step-by-step instructions for takeoff, flying, landing, and taxiing. It was as
if someone all of a sudden gave an experienced automobile driver a checklist of
things that would be obvious to them. There was nothing on the checklist they
didn't know. Stuff like, check that the instruments are set, the door closed.
Basics. That checklist changed the course of history and quite possibly the
war. The pilots went on to fly the Model 299 a “total of 1.8 million miles”
without a single accident and as a result the army ordered over 13,000 of them.”
Most of the today's industries are using checklist in one or
in another form, as suggested by Atul:
Substantial parts of what software designers, financial
managers, firefighters, police officers, lawyers, and most certainly clinicians
do are now too complex for them to carry out reliably from memory alone.
When things change, you're now faced with a non-routine
problem. “The philosophy,” writes Atul, “is that you push the power of decision
making out to the periphery and away from the center. You give people the room
to adapt, based on their experience and expertise. All you ask is that they
talk to one another and take responsibility. That is what works.”
“The real lesson is that under
conditions of true complexity—where the knowledge required exceeds that of any
individual and unpredictability reigns—efforts to dictate every step from the
center will fail. People need room to act and adapt. Yet they cannot succeed as
isolated individuals, either—that is anarchy. Instead, they require a seemingly
contradictory mix of freedom and expectation—expectation to coordinate, for
example, and also to measure progress toward common goals.
That routine requires balancing a number of virtues: freedom and discipline,
craft and protocol, specialized ability and group collaboration. And for
checklists to help achieve that balance, they have to take two almost opposing
forms. They supply a set of checks to ensure the stupid but critical stuff is
not overlooked, and they supply another set of checks to ensure people talk and
coordinate and accept responsibility while nonetheless being left the power to
manage the nuances and unpredictabilities the best they know how.
This was the understanding people in
the skyscraper-building industry had grasped. More remarkably, they had learned
to codify that understanding into simple checklists. They had made the reliable
management of complexity a routine.”
From the book, Seeking wisdom from Darwin toMunger by Peter Bevelin:
Checklist procedures :
“Air carrier cockpit checklists to
be reviewed in an effort to ensure that
each list provides a means of reminding the crew, immediately prior to
takeoff, that all items critical for safe flight have been accomplished.
- National Transportation Safety Board, 1969”
in the book an incident is shared as -
"In 1987, NorthwestAirlines flight
255 crashed shortly after take-off. All 155 persons
aboard expect one were killed. A federal report concluded that the probable
cause of
the accident was the flight crew's failure to use the taxi checklist to ensure
that the flaps
and slats were extended for takeoff. Contributing to the accident was the
absence of
electrical power to the airplane's takeoff warning system, which consequently
could
not warn the flight crew that the airplane was not configured properly for
takeoff.
Use checklist procedures. Together with other tools they help us reduce the
chance of harm. Concentrate on the critical items. If we don't check for them
we
may get harmed. Pilots call these the "killer items."
Charles Munger suggests using models in a checklist fashion:
“I think you need mental models -
and what I call checklist procedures - where you take a worthwhile list of
models and run right down them: "Is this here? Is that here?"
and so on and so on ... Now if there are two or three items that are
very important that aren't on your checklist - well, if you're an airplane
pilot, you can crash. Likewise, if you're trying to analyze a company
without using an adequate checklist, you may make a very bad investment.”
Some issues to think about when designing checklists are:
- Different issues need different checklists.
- A checklist must include each critical item necessary for
"safety" and avoiding "accidents" so we don't need to rely
on memory for items to be checked.
- Readily usable and easy to use.
- Agree with reality.
Doing something according to pre-established rules, filters
and checklists often makes more sense than doing something out of pure emotion.
But we can't have too many rules, filters or items without thinking. We must
always understand what we're trying to accomplish.
In the book The Checklist manifesto Atul
have shared many real time incidents, one of those is shared below –
“One more aviation checklist story,
this one relatively recent. The incident occurred on January 17, 2008, as
British Airways Flight 38 approached London from Beijing after almost eleven
hours in the air with 152 people aboard. The Boeing 777 was making its final
descent into Heathrow airport. It was just past noon. Clouds were thin and
scattered. Visibility was more than six miles. The wind was light, and the
temperature was mild despite the season—50 degrees Fahrenheit. The flight
had been completely uneventful to this point. Then, at two miles from the
airport, 720 feet over a residential neighborhood, just when the plane should
have accelerated slightly to level off its descent, the engines gave out. First
the right engine rolled back to minimal power, then the left. The copilot was
at the controls for the landing, and however much he tried to increase thrust,
he got nothing from the engines. For no apparent reason, the plane had gone
eerily silent. He extended the wing flaps to make the plane glide as much as
possible and to try to hold it on its original line of approach. But the
aircraft was losing forward speed too quickly. The plane had become a
350,000-pound stone falling out of the air. Crash investigators with Britain’s
Air Accidents Investigation Branch later determined that it was falling twenty-three
feet per second. At impact, almost a quarter mile short of the runway, the
plane was calculated to be moving at 124 miles per hour Only by sheer luck
was no one killed, either on board or on the ground. The plane narrowly missed
crashing through the roofs of nearby homes. Passengers in cars on the perimeter
road around Heathrow saw the plane coming down and thought they were about to
be killed. Through a coincidence of international significance, one of those
cars was carrying British prime minister Gordon Brown to his plane for his
first official visit to China. “It was just yards above our heads, almost
skimming a lamppost as the plane came in very fast and very, very low,” an aide
traveling with the prime minister told London’s Daily Mirror. The aircraft hit
a grassy field just beyond the perimeter road with what a witness described as
“an enormous bang.” The nose wheels collapsed on impact. The right main landing
gear separated
from the aircraft, and its two right front wheels broke away, struck the right
rear fuselage, and penetrated through the passenger compartment at rows 29 and
30. The left main landing gear pushed up through the wing. Fourteen hundred
liters of jet fuel came pouring out. Witnesses saw sparks, but somehow the fuel
did not ignite. Although the aircraft was totaled by the blunt force of the
crash, the passengers emerged mostly unharmed— the plane had gone into a
thousand-foot ground slide that slowed its momentum and tempered the impact.
Only a dozen or so passengers required hospitalization. The worst injury was a
broken leg. Investigators from the AAIB were on the scene within an hour trying
to piece together what had happened. Their initial reports, published one month
and then four months after the crash, were documents of frustration. They
removed the engines, fuel system, and data recorders and took them apart piece
by piece. Yet they found no engine defects whatsoever. The data download showed
that the fuel flow to the engines had reduced for some reason, but inspection of
the fuel feed lines with a boroscope—a long fiberoptic videoscope—showed no
defects or obstructions. Tests of the valves and wiring that controlled fuel
flow showed they had all functioned properly. The fuel tanks contained no
debris that could have blocked the fuel lines
Attention therefore turned to the fuel itself. Tests showed it to be normal Jet
A-1 fuel. But investigators, considering the flight’s path over the Arctic
Circle, wondered: could the fuel have frozen in flight, caused the crash, then
thawed before they could find a trace of it? The British Airways flight had
followed a path through territory at the border of China and Mongolia where the
recorded ambient air temperature that midwinter day was −85 degrees
Fahrenheit. As the plane crossed the Ural Mountains and Scandinavia, the
recorded temperature fell to −105 degrees. These were not considered
exceptional temperatures for polar flight. Although the freezing point for Jet
A-1 fuel is −53 degrees, the dangers were thought to have been resolved.
Aircraft taking Arctic routes are designed to protect the fuel against extreme
cold, and the pilots monitor the fuel temperature constantly. Crosspolar routes
for commercial aircraft opened in February 2001, and thousands of planes have
traveled them without incident since. In fact, on the British Airways flight,
the lowest fuel temperature recorded was −29 degrees, well above the fuel’s
freezing point. Furthermore, the plane was over mild-weathered London, not the
Urals, when the engines lost power. Nonetheless, investigators remained
concerned that the plane’s flight path had played a role. They proposed an
elaborate theory. Jet fuel normally has a minor amount of water moisture in it,
less than two drops per gallon. During cold-air flights, the moisture routinely
freezes and floats in the fuel as a suspension of tiny ice crystals. This had
never been considered a signifi- cant problem. But maybe on a long, very smooth
polar flight—as this one was—the fuel flow becomes so slow that the crystals
have time to sediment and perhaps accumulate somewhere in the fuel tank. Then,
during a brief burst of acceleration, such as on the final approach, the sudden
increase in fuel flow might release the accumulation, causing blockage of the
fuel lines.
The investigators had no hard evidence for this idea. It seemed a bit like
finding a man suffocated in bed and arguing that all the oxygen molecules had
randomly jumped to the other end of the room, leaving him to die in his
sleep—possible, but preposterously unlikely. Nonetheless, the investigators
tested what would happen if they injected water directly into the fuel system
under freezing conditions. The crystals that formed, they found, could indeed
clog the lines. Almost eight months after the crash, this was all they had for
an explanation. Everyone was anxious to do something before a similar accident
occurred. Just in case the explanation was right, the investigators figured out
some midflight maneuvers to fix the problem. When an engine loses power, a
pilot’s instinct is to increase the thrust—to rev the engine. But if ice
crystals have accumulated, increasing the fuel flow only throws more crystals
into the fuel lines. So the investigators determined that pilots should do the
opposite and idle the engine momentarily. This reduces fuel flow and permits
time for heat exchangers in the piping to melt the ice—it takes only
seconds—allowing the engines to recover. At least that was the investigators’
best guess. So in September 2008, the Federal Aviation Administration in the
United States issued a detailed advisory with new procedures pilots should
follow to keep ice from accumulating on polar flights and also to recover
flight control if icing nonetheless caused engine failure. Pilots across the
world were somehow supposed to learn about these findings and smoothly
incorporate them into their flight practices within thirty days. The remarkable
thing about this episode—and the reason the story is worth telling—is that the
pilots did so.
How this happened—it involved a checklist, of course—is instructive. But first
think about what happens in most lines of professional work when a major
failure occurs. To begin with, we rarely investigate our failures. Not in
medicine, not in teaching, not in the legal profession, not in the financial
world, not in virtually any other kind of work where the mistakes do not turn
up on cable news. A single type of error can affect thousands, but because it
usually touches only one person at a time, we tend not to search as hard for
explanations.”
What are the other areas where you can apply the checklist
to make the right decisions are to avoid the errors or mistakes, some of them
are below:
- In medical field, in operations, surgery etc.
- In Aviation industry, as we discussed above in the post.
- In Real estate and construction industry, you can get a
sense of it in my other post.
- In Software industry when you prepare the unit test plans.
It's nothing but the changed name of checklist only.
- In Pharmacy industry, you follow a certain guideline while
preparing the medicines.
- In Stock investment, you prepare your own checklist and
you cross verify your investment against the checklist-it’s very useful in
investing.
- In life, while taking major decisions like buying house.
- In any plant construction, like constructing the Nuclear
plan. We need to follow many checkpoint and we need to take care of margin of safety as
well.
- In military operations, the military works on rules and
guidelines only. It’s one kind of checklist and it’s a discipline in military.
- When working in teams to achieve a specified goal,
we design some rules to follow that are nothing but a form of checklist.
There are many examples from real life, you can share your
examples in the comment and you can subscribe to my blog, to get the post
notification in your email.
There are many other interesting posts shared on my blogs,
you can read some of them by clicking on the below link:
- Margin of safety to
get the odds in your favor.
- Journal writing, to
arrange your thought and help you to make right decisions in life and in work.
There are many more, you can read on this blog.
Thanks for reading and keep learning.
- Mahesh
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