The Checklist Manifesto (10 page)

Nevertheless, the authorities refused to abandon the traditional model. For days, while conditions deteriorated hourly, arguments roared over who had the power to provide the resources and make decisions. The federal government wouldn’t yield the power to the state government. The state government wouldn’t give it to the local government. And no one would give it to people in the private sector.

The result was a combination of anarchy and Orwellian bureaucracy with horrifying consequences. Trucks with water and food were halted or diverted or refused entry by authorities—the supplies were not part of their plan. Bus requisitions were held up for days; the official request did not even reach the U.S. Department of Transportation until two days after tens of thousands had become trapped and in need of evacuation. Meanwhile two hundred local transit buses were sitting idle on higher ground nearby.

The trouble wasn’t a lack of sympathy among top officials. 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. Everyone was waiting for the cavalry, but a centrally run, government-controlled solution was not going to be possible.

Asked afterward to explain the disastrous failures, Michael Chertoff, secretary of Homeland Security, said that it had been an “ultra-catastrophe,” a “perfect storm” that “exceeded the
foresight of the planners, and maybe anybody’s foresight.” But that’s not an explanation. It’s simply the definition of a complex situation. And such a situation requires a different kind of solution from the command-and-control paradigm officials relied on.

Of all organizations, it was oddly enough Wal-Mart that best recognized the complex nature of the circumstances, according to a case study from Harvard’s Kennedy School of Government. Briefed on what was developing, the giant discount retailer’s chief executive officer, Lee Scott, issued a simple edict. “This company will respond to the level of this disaster,” he was remembered to have said in a meeting with his upper management. “A lot of you are going to have to make decisions above your level. Make the best decision that you can with the information that’s available to you at the time, and, above all, do the right thing.”

As one of the officers at the meeting later recalled, “That was it.” The edict was passed down to store managers and set the tone for how people were expected to react. On the most immediate level, Wal-Mart had 126 stores closed due to damage and power outages. Twenty thousand employees and their family members were displaced. The initial focus was on helping them. And within forty-eight hours, more than half of the damaged stores were up and running again. But according to one executive on the scene, as word of the disaster’s impact on the city’s population began filtering in from Wal-Mart employees on the ground, the priority shifted from reopening stores to “Oh, my God, what can we do to help these people?”

Acting on their own authority, Wal-Mart’s store managers began distributing diapers, water, baby formula, and ice to residents.
Where FEMA still hadn’t figured out how to requisition supplies, the managers fashioned crude paper-slip credit systems for first responders, providing them with food, sleeping bags, toiletries, and also, where available, rescue equipment like hatchets, ropes, and boots. The assistant manager of a Wal-Mart store engulfed by a thirty-foot storm surge ran a bulldozer through the store, loaded it with any items she could salvage, and gave them all away in the parking lot. When a local hospital told her it was running short of drugs, she went back in and broke into the store’s pharmacy—and was lauded by upper management for it.

Senior Wal-Mart officials concentrated on setting goals, measuring progress, and maintaining communication lines with employees at the front lines and with official agencies when they could. In other words, to handle this complex situation, they did not issue instructions. Conditions were too unpredictable and constantly changing. They worked on making sure people talked. Wal-Mart’s emergency operations team even included a member of the Red Cross. (The federal government declined Wal-Mart’s invitation to participate.) The team also opened a twenty-four-hour call center for employees, which started with eight operators but rapidly expanded to eighty to cope with the load.

Along the way, the team discovered that, given common goals to do what they could to help and to coordinate with one another, Wal-Mart’s employees were able to fashion some extraordinary solutions. They set up three temporary mobile pharmacies in the city and adopted a plan to provide medications for free at all of their stores for evacuees with emergency needs—even without a prescription. They set up free check cashing for payroll and other checks in disaster-area stores. They opened temporary clinics to provide emergency personnel with inoculations against
flood-borne illnesses. And most prominently, within just two days of Katrina’s landfall, the company’s logistics teams managed to contrive ways to get tractor trailers with food, water, and emergency equipment past roadblocks and into the dying city. They were able to supply water and food to refugees and even to the National Guard a day before the government appeared on the scene. By the end Wal-Mart had sent in a total of 2,498 trailer loads of emergency supplies and donated $3.5 million in merchandise to area shelters and command centers.

“If the American government had responded like Wal-Mart has responded, we wouldn’t be in this crisis,” Jefferson Parish’s top official, Aaron Broussard, said in a network television interview at the time.

The lesson of this tale has been misunderstood. Some have argued that the episode proves that the private sector is better than the public sector in handling complex situations. But it isn’t. For every Wal-Mart, you can find numerous examples of major New Orleans businesses that proved inadequately equipped to respond to the unfolding events—from the utility corporations, which struggled to get the telephone and electrical lines working, to the oil companies, which kept too little crude oil and refinery capacity on hand for major disruptions. Public officials could also claim some genuine successes. In the early days of the crisis, for example, the local police and firefighters, lacking adequate equipment, recruited an armada of Louisiana sportsmen with flat-bottom boats and orchestrated a breathtaking rescue of more than sixty-two thousand people from the water, rooftops, and attics of the deluged city.

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.

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.

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.

I came away from Katrina and the builders with a kind of theory: under conditions of complexity, not only are checklists a help, they are
required
for success. There must always be room for judgment, but judgment aided—and even enhanced—by procedure.

Having hit on this “theory,” I began to recognize checklists in odd corners everywhere—in the hands of professional football coordinators, say, or on stage sets. Listening to the radio, I heard the story behind rocker David Lee Roth’s notorious insistence
that Van Halen’s contracts with concert promoters contain a clause specifying that a bowl of M&M’s has to be provided backstage, but with every single brown candy removed, upon pain of forfeiture of the show, with full compensation to the band. And at least once, Van Halen followed through, peremptorily canceling a show in Colorado when Roth found some brown M&M’s in his dressing room. This turned out to be, however, not another example of the insane demands of power-mad celebrities but an ingenious ruse.

As Roth explained in his memoir,
Crazy from the Heat
, “Van Halen was the first band to take huge productions into tertiary, third-level markets. We’d pull up with nine eighteen-wheeler trucks, full of gear, where the standard was three trucks, max. And there were many, many technical errors—whether it was the girders couldn’t support the weight, or the flooring would sink in, or the doors weren’t big enough to move the gear through. The contract rider read like a version of the Chinese Yellow Pages because there was so much equipment, and so many human beings to make it function.” So just as a little test, buried somewhere in the middle of the rider, would be article 126, the no-brown-M&M’s clause. “When I would walk backstage, if I saw a brown M&M in that bowl,” he wrote, “well, we’d line-check the entire production. Guaranteed you’re going to arrive at a technical error…. Guaranteed you’d run into a problem.” These weren’t trifles, the radio story pointed out. The mistakes could be life-threatening. In Colorado, the band found the local promoters had failed to read the weight requirements and the staging would have fallen through the arena floor.

“David Lee Roth had a checklist!” I yelled at the radio.

I ran my theory—about the necessity of checklists—by Jody
Adams, the chef and own er of Rialto, one of my favorite restaurants in Boston. In the early 1990s,
Food and Wine
magazine named her one of America’s ten best new chefs, and in 1997 she won a James Beard Foundation Best Chef award, which is the Oscar for food. Rialto is frequently mentioned on national best-restaurant lists, most recently
Esquire
magazine’s. Her focus is on regional Italian cuisine, though with a distinctive take.

Adams is self-taught. An anthropology major at Brown University, she never went to culinary school. “But I had a thing for food,” as she puts it, and she went to work in restaurants, learning her way from chopping onions to creating her own style of cooking.

The level of skill and craft she has achieved in her restaurant is daunting. Moreover, she has sustained it for many years now. I was interested in how she did it. I understood perfectly well how the Burger Kings and Taco Bells of the world operate. They are driven by tightly prescribed protocol. They provide Taylorized, assembly-line food. But in great restaurants the food is ever-evolving, refined, and individual. Nevertheless, they have to produce an extraordinary level of excellence day after day, year after year, for one to three hundred people per night. I had my theory of how such perfectionism is accomplished, but was it true? Adams invited me in to see.

I spent one Friday evening perched on a stool in Rialto’s long and narrow kitchen amid the bustle, the shouting, the grill flaming on one side, the deep fryer sizzling on another. Adams and her staff served 150 people in five hours. That night, they made a roasted tomato soap with sweated onions and garlic; squid ink ravioli filled with a salt cod brandade on a bed of squash blossoms and lobster sauce; grilled bluefish with corn relish, heirloom
tomatoes, and pickled peppers; slow-roasted duck marinated in soy sauce, balsamic vinegar, mustard, rosemary, and garlic; and three dozen other mouthwatering dishes.

Sitting there, I saw remarkable expertise. Half of Adams’s staff had been to culinary school. Few had less than a decade of experience. They each had a kitchen specialty. There was a pastry chef, baker, grill chef, fry cook, dessert chef, sous chef, sommelier—you get the picture. Through the years, they had perfected their technique. I couldn’t fathom the subtleties of most of what they did. Though I am a surgeon, they wouldn’t let me anywhere near their knives. Jay, the pasta chef, showed me how to heat butter properly and tell by sight when gnocchi were perfectly boiled. Adams showed me how much a pinch of salt really was.

People celebrate the technique and creativity of cooking. Chefs are personalities today, and their daring culinary exploits are what make the television cooking shows so popular. But as I saw at Rialto, it’s discipline—uncelebrated and untelevised—that keeps the kitchen clicking. And sure enough, checklists were at the center of that discipline.

First there was the recipe—the most basic checklist of all. Every dish had one. The recipes were typed out, put in clear plastic sleeves, and placed at each station. Adams was religious about her staff ’s using them. Even for her, she said, “following the recipe is essential to making food of consistent quality over time.”

Tacked to a bulletin board beside the dessert station was what Adams called her Kitchen Notes—e-mails to the staff of her brief observations about the food. The most recent was from 12:50 the previous night. “Fritters—more herbs, more garlic … more punch,” it said. “Corn silk in corn! Creamed corn side on oval
plates—not square! Mushrooms—more shallots, garlic, and marsala. USE THE RECIPES!”

The staff didn’t always love following the recipes. You make the creamed corn a few hundred times and you believe you have it down. But that’s when things begin to slip, Adams said.

The recipes themselves were not necessarily static. All the ones I saw had scribbled modifications in the margins—many of them improvements provided by staff. Sometimes there would be a wholesale revamp.