Gawande also looked to the commercial aircraft industry, which has an outstanding safety record. Boeing has been a pioneer in developing checklists that give pilots guidance on what to do in situations ranging from the routine, like starting an engine before taxiing to the runway, to emergency situations arising out of such events as a cargo door coming unsealed during flight at high altitude. It was a checklist that helped insure the safe water landing in the Hudson River of US Airways Flight 1549, which, on January 14, 2009, took off from New York's La Guardia Airport, ran into a flock of geese, and lost power from both its engines.
Motivated by the practices of the construction and aircraft industries, Gawande and his team developed a checklist for the operating room and tested its efficacy over a six-month period in eight hospitals around the world. The results were far better than expected. With the use of checklists, major complications arising out of surgical procedures fell by 36 percent, and deaths fell by 47 percent. Gawande was ecstatic, and the enthusiasm for the practice that he expresses in his manifesto is infectious.
Can there be a checklist for the design process? On the one hand, unlike surgical operations, construction projects, and aircraft maneuvers, which typically follow proven procedures, design is the very act of creating something that cannot be fully proven until it is made and tested. On the other hand -- like surgeons, construction managers, and pilots -- designers can make mistakes that result in failures. It could very well be the case that a properly devised checklist for design could prevent some of those mistakes from being made.
Among the items that might be considered for a design checklist are the following:
Can the design under consideration be manufactured at a reasonable cost?
Can a part of the overall design be installed in the wrong way?
Will the design be able to withstand the environment in which it is expected to operate?
Does the design call for direct contact of dissimilar metals susceptible to galvanic corrosion?
Does the fatigue life of its components at least equal that expected of the design as a whole?
Is the human interface intuitive and unambiguous?
The specific questions to appear on a design checklist would naturally depend upon the nature of the industry involved. In any case, however, designers, like surgeons, can be expected to be skeptical of such an encroachment upon their professional space. But if the results were found to be as good as surgeons have experienced, then designers might become converts as enthusiastic as Dr. Gawande.
Dr. Petroski—excellent article! I suppose I'm really uninformed. I thought that surely all surgeons had some form of WRITTEN checklist prior to performing an operation. As an engineering program manager, I would never start a program without a schedule indicating critical path AND a checklist noting those items necessary to accomplish completion. It becomes even more important when differing design and drafting locations are involved. I know you don't have the location issue with surgery but one very tired surgeon operating day after day will make mistakes. It's not if but when. My own doctor has indicated to me several times he needs an IE to examine the organizational aspects of his office. The "doctoring" is quite adequate but front office staff run the place like a zoo.
JimT I agree with you. As a designer I certainly have a mental checklist but I believe the key word is "written". One of my college professors would always make us write stuff down because he said "if you write it down then that says you have thought about it". I agree most of the time if you write something down you have thought about it.
fixated has negative connotations. BUMPFF was RAF standard finals check mnemonic before landing on propellor driven aircraft. i think 'brakes off' is an important check. not fixated at all...just pointing out something missing in your checklist. however if you feel you do not need to check that the brakes are off prior to landing...well, i guess thats up to you.
I remember once when I was doing a product commissioning in another country, the customer had a consultant who lived and died by his ever-present check lists. While that made him extremely thorough in his own area of expertise, it caused a certain amount of gamesmanship among some of the others. He obviously couldn't know the details of every component to be checked, so he had to rely on others to furnish the information necessary to create the checklists. I found some people to be very creative in the information they gave him so as to receive very generic responsibilities on the checklist.
In a world that's going green, industrial operations have a problem: Their processes involve materials that are potentially toxic, flammable, corrosive, or reactive. If improperly managed, this can precipitate dangerous health and environmental consequences.
Government regulations, coupled with growing consumer sensitivity about data and identity theft, require that data storage organizations demonstrate proper protection and due diligence in protecting sensitive information stored inside datacenter enclosures.
When a crane doesn't have a monitoring system, crane owners schedule service every six months and simply scrap the parts they replace, even if a part has had little use and doesn't need replacing. This can cost thousands.
A quick look into the merger of two powerhouse 3D printing OEMs and the new leader in rapid prototyping solutions, Stratasys. The industrial revolution is now led by 3D printing and engineers are given the opportunity to fully maximize their design capabilities, reduce their time-to-market and functionally test prototypes cheaper, faster and easier. Bruce Bradshaw, Director of Marketing in North America, will explore the large product offering and variety of materials that will help CAD designers articulate their product design with actual, physical prototypes. This broadcast will dive deep into technical information including application specific stories from real world customers and their experiences with 3D printing. 3D Printing is