Free The Checklist Manifesto by Atul Gawande Page B

individual judgments, but they had to do so as part of a team that took one another’s concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems,they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction—who had to share (or “submit”) particular kinds of information before the next steps could proceed.
    The submittal schedule specified, for instance, that by the end of the month the contractors, installers, and elevator engineers had to review the condition of the elevator cars traveling up to the tenth floor. The elevator cars were factory constructed and tested. They were installed by experts. But it was not assumed that they would work perfectly. Quite the opposite. The assumption was that anything could go wrong, anything could get missed. What? Who knows? That’s the nature of complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.
    So the submittal schedule made them talk. The contractors had to talk with the installers and elevator engineers by the thirty-first. They had to talk about fire protection with the fireproofers by the twenty-fifth. And two weeks earlier, they had been required to talk about the condition of the core wall and flooring on the upper floors, where the water had pooled, with the structural engineers, a consultant, and the owners.
    I saw that the box had been checked. The task was done. I asked Rouillard how the discussion had gone.
    Very well, he said. Everyone met and reviewed the possibilities. The owners and the contractors were persuaded that it was reasonable to expect the floor to level out. Cleanup was arranged, the schedule was adjusted, and everyone signed off.
    In the face of the unknown—the always nagging uncertainty about whether, under complex circumstances, things will really be okay—the builders trusted in the power of communication. They didn’t believe in the wisdom of the single individual, of even an experienced engineer. They believed in the wisdom of the group, the wisdom of making sure that multiple pairs of eyes were on a problem and then letting the watchers decide what to do.
    Man is fallible, but maybe men are less so.
    In a back room of the field office, Ryan Walsh, a buzz-cut young man of about thirty wearing a yellow reflector vest, sat in front of two big flat-screen displays. His job, he explained, was to take all the construction plans submitted by each of the major trades and merge them into a three-dimensional floor-by-floor computer rendering of the building. He showed me what the top floor looked like on the screen. He’d so far loaded in the specifications from nine of the trades—the structural specs, the elevator specs, the plumbing specs, and so on. He used his mouse to walk us through the building as if we were taking a stroll down the corridors. You could see the walls, the doors, the safety valves, everything. More to the point, you could see problems—a place where there wasn’t enough overhead clearance for an average-size person, for example. He showed me an application called Clash Detective that ferreted out every instance in which the different specs conflicted with one another or with building regulations.
    “If a structural beam is going where a lighting fixture is supposed to hang, the Clash Detective turns that beam a different color on-screen,” he said. “You can turn up hundreds of clashes. Ionce found two thousand.” But it’s not enough to show the clash on the screen, he explained. You have to resolve it, and to do that you have to make sure the critical people talk. So the computer also flags the issue for the submittal schedule printout and sends an e-mail to each of the parties who