The first is ignorance—we may err because science has given us only a partial understanding of the world and how it works. LOCATION: 114
The second type of failure the philosophers call ineptitude—because in these instances the knowledge exists, yet we fail to apply it correctly. LOCATION: 116
But sometime over the last several decades—and it is only over the last several decades—science has filled in enough knowledge to make ineptitude as much our struggle as ignorance. LOCATION: 122
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. LOCATION: 181
Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all. LOCATION: 447
Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance. LOCATION: 453
First, how could they be sure that they had the right knowledge in hand? Second, how could they be sure that they were applying this knowledge correctly? LOCATION: 654
The philosophy 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. LOCATION: 910
It was a lack of understanding that, in the face of an extraordinarily complex problem, power needed to be pushed out of the center as far as possible. LOCATION: 943
No, 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. LOCATION: 987
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. LOCATION: 993
There have been psychology studies in various fields backing up what should have been self-evident—people who don’t know one another’s names don’t work together nearly as well as those who do. LOCATION: 1360
Good checklists, on the other hand, are precise. They are efficient, to the point, and easy to use even in the most difficult situations. They do not try to spell out everything—a checklist cannot fly a plane. Instead, they provide reminders of only the most critical and important steps—the ones that even the highly skilled professionals using them could miss. Good checklists are, above all, practical. LOCATION: 1512
You must decide whether you want a DO-CONFIRM checklist or a READ-DO checklist. With a DO-CONFIRM checklist, he said, team members perform their jobs from memory and experience, often separately. But then they stop. They pause to run the checklist and confirm that everything that was supposed to be done was done. With a READ-DO checklist, on the other hand, people carry out the tasks as they check them off—it’s more like a recipe. So for any new checklist created from scratch, you have to pick the type that makes the most sense for the situation. LOCATION: 1546
The checklist cannot be lengthy. A rule of thumb some use is to keep it to between five and nine items, which is the limit of working memory. LOCATION: 1550
Even the look of the checklist matters. Ideally, it should fit on one page. It should be free of clutter and unnecessary colors. It should use both uppercase and lowercase text for ease of reading. (He went so far as to recommend using a sans serif type like Helvetica.) LOCATION: 1558
It is common to misconceive how checklists function in complex lines of work. They are not comprehensive how-to guides, whether for building a skyscraper or getting a plane out of trouble. They are quick and simple tools aimed to buttress the skills of expert professionals. LOCATION: 1619