What do medicine and aviation have in common with the governance of organisations? Well, one thing is that they need to confront what Atul Gawande has described as ‘the problem of extreme complexity.’ (1)
A surgeon, as well as a compelling writer, Gawande says that “Medicine has become the art of managing extreme complexity – and a test of whether such complexity can, in fact, be humanly mastered.” Medicine’s response to this complexity has been to divide the tasks up among various specialities. There is pressure to do the same in the boardroom to handle new and emerging issues. In Gawande’s experience, however, even divvied up the work can be overwhelming. It’s not only the breadth and quantity of knowledge, he says, that has made medicine complicated. It is also the execution, the practical matter of putting knowledge into practice. Mistakes are still made. According to Gawande, in the US, at least half of deaths and major complications following surgery are avoidable.
The answer came from the sky
So, what do you do when expertise is not enough? The answer Gawande found was in a source that had nothing to do with medicine at all. It was in aviation.
In 1935, the spectacular crash of a new, long-range bomber on a trial flight for the US Army Air Corps was initially put down to ‘pilot error’. Flying it was complex, but some in the air corps considered it might be worth persevering with the new aircraft. So, a few of the new planes were ordered to give a group of test pilots the chance to see what they could figure out.
A Pilots Checklist
The pilots found that the steps needed to keep the new aircraft safe were too complicated to be left to one person’s memory, however expert. Their solution was simple – a pilot’s checklist. Brief enough to fit on an index card, it listed the critical actions required for safe take-off, flight, landing, and taxiing of the new bomber. These were all things pilots knew how to do. However, applying the discipline of the checklist made sure these were each attended to and in the correct order. With the checklist in hand, the pilots flew nearly 2 million miles without further accident. The US Army ultimately ordered almost 13,000 of the aircraft, which became known as the B-17 or the ‘flying fortress’. It gave US forces a decisive advantage in WW2. (2).
Can boards benefit from a checklist?
So, might boards also benefit from a checklist approach? It’s not that the process of governing organisations is so obviously a minute-by-minute matter of life and death as in a hospital or in an aircraft. However, a board’s decisions (or lack thereof) can also have tremendous consequences. A board is responsible for the wellbeing of an entire organisation and the often extensive and complex range of stakeholders who depend on it. Lives are often at stake here, too, and a board can also be faced with very stressful situations. Boards are having to come to terms with all manner of increasing responsibilities. Many of these are being sheeted home by legislation and regulation. Consequently, boards are having to choose in a situation of rapidly growing complexity which of a myriad of potential tasks get their attention, and in what order. Muddling through is no longer an option.
The B17 Phase
Gawande speculated that much of the work in organisations today has entered a kind of ‘B-17’ phase. With multiple fields to be attended to, perhaps organisations have become ‘too much plane for one person to fly’. He says experts are up against two main difficulties in a complex environment: memory and attention. This is especially true when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events. Faulty memory and distraction are a particular danger in situations where if even one key thing is missed, the result can be dire.
These concerns will resonate with many board members. They and their boards are often time-poor. This affects the thoroughness of their preparation for everything from routine monitoring to ‘bet the farm’ decisions. In addition, attention deficits are often apparent during board meetings given, for one thing, the proliferation of devices that connect them in real-time to potential distractions outside the boardroom.
Checklists address weakness
Matthew Syed has pointed to another weakness that could be addressed by a checklist approach: the impact of status differences on board dynamics. Coincidentally, awareness of this opportunity arose from another aviation mishap. (3) In 1978, a United Airlines flight ran out of fuel and crashed because the captain lost track of time while focused on solving a landing gear problem. Others on the flight deck (a co-pilot and engineer) voiced their concerns but did not challenge him directly about the dwindling fuel situation. The undue deference flowing from status differences among the flight crew had fatal consequences.
The pecking order of influence
Legally, all members of a board have shared and equal accountability. However, on almost every board, there is a tangible ‘pecking order’ of influence. This can be based on many variables and may be static or dynamic. For example, if based primarily on individual experience or professional expertise, it can change even within a board meeting according to what is being discussed.
Status differences and social hierarchies, compounded by the sporadic nature of board meetings, tend to hinder group formation, and allows communication barriers to persist. As Syed observes, most people talk to those in authority in somewhat deferential terms which he refers to as ‘mitigated language’. (4) This makes sense in some situations, but in others, it can be fatal. Flight UA 173 and other examples Syed described demonstrated that the problem was not a lack of diligence or motivation but a system insensitive to the limitations of human psychology.
Checklists flatten the hierarchy
Syed’s analysis underlines the potential value of checklists in these kinds of situations as well. The aviation industry’s response to what was learned from the UA 173 situation was to take checklists already in operation and ensure they were expanded and improved. Checklists “…have been established as a means of preventing oversights in the face of complexity. But they also flatten the hierarchy. When pilots and co-pilots talk to each other, introduce themselves and go over the checklist, they open channels of communication. It makes it more likely the junior partner will speak up in an emergency.” (5)
It is not hard to think of a wide range of checklists that would be helpful to boards and their executive teams. Not least, a checklist of steps to be taken, for example, in making a high stakes decision. In their recent bestseller ‘Noise’, Kahneman, Sibony and Sunstein advocate for (and offer an example of) a checklist of the kind of biases that can undermine decision quality. They say that “the case for relying on checklists is clear: checklists have a long history of improving decisions in high-stakes contexts and are particularly well suited to preventing the repetition of past errors.” (6)
(1) Atul Gawande (2010) The Checklist Manifesto: How to Get Things Right. London, Profile Books, Chapter 1 ‘The Problem of Extreme Complexity’.
(2) Gawande (2010, 34). Note this page reference is in the E-book version and may differ from the hardcopy version.
(3) Matthew Syed (2015) Black Box Thinking. New York, Portfolio/Penguin. Chapter 2 ‘United Airlines 173’.
(4) Syed (2015, 28)
(5) Syed (2015, 30)
(6) Daniel Kahneman, Oliver Sibony and Cass R. Sunstein (2021) Noise: A Flaw in Huma Judgement. London, William Collins. Pp.240-241. Note this page reference is in the E-book version and may differ from the hardcopy version.
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