The Checklist Manifesto (9 page)

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. I
once 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 have to resolve it.

There’s yet another program, called ProjectCenter, that allows anyone who has found a problem—even a frontline worker—to e-mail all the relevant parties, track progress, and make sure a check is added to the schedule to confirm that everyone has talked and resolved the matter. When we were back at the McNamara/Salvia offices, Bernie Rouillard showed me one such e-mail he’d gotten that week. A worker had attached a digital photo of a twelve-foot steel I beam he was bolting in. It hadn’t lined up properly and only two of the four bolts could fit. Was that all right, the worker wanted to know? No, Rouillard wrote back. They worked out a solution together: to weld the beam into place. The e-mail was also automatically sent to the main contractor and anyone else who might potentially be required to sign off. Each party was given three days to confirm that the proposed solution was okay. And everyone needed to confirm they’d communicated, since the time taken for even this small fix could change the entire sequence in which other things needed to be done.

Joe Salvia had earlier told me that the major advance in the science of construction over the last few decades has been the perfection of tracking and communication. But only now did I understand what he meant.

The building world’s willingness to apply its strategies to difficulties of any size and seriousness is striking. Salvia’s partner, Robert
McNamara, for instance, was one of the structural engineers for the Citicorp (now Citigroup) building in midtown Manhattan, with its iconic slanted rooftop. It was planned to rise more than nine hundred feet on four nine-story-tall stiltlike columns placed not at the building’s corners but at the center of each side and steadied by giant, hidden chevron-shaped braces designed by William LeMessurier, the project’s lead structural engineer. The visual effect was arresting. The colossal structure would look like it was almost floating above Fifty-third Street. But wind-tunnel testing of a model revealed that the skyscraper stood so high above the surrounding buildings in midtown that it was subject to wind streams and turbulence with forces familiar only to airplane designers, not to structural engineers. The acceptable amount of sway for the building was unknown.

So what did they do? They did not scrap the building or shrink it to a less ambitious size. Instead, McNamara proposed a novel solution called a “tuned mass damper.” They could, he suggested, suspend an immense four-hundred-ton concrete block from huge springs in the building’s crown on the fifty-ninth floor, so that when wind pitched the building one way, the block would swing the other way and steady it.

The solution was brilliant and elegant. The engineers did some wind-tunnel testing with a small model of the design, and the results were highly reassuring. Nonetheless, some chance of error and unpredictability always remains in projects of this complexity. So the builders reduced their margin of error the best way they knew how—by taking a final moment to make sure that everyone talked it through as a group. The building owner met with the architect, someone from the city buildings department, the structural engineers, and others. They reviewed the
idea and all the calculations behind it. They confirmed that every concern they could think of had been addressed. Then they signed off on the plan, and the skyscraper was built.

It is unnerving to think that we allow buildings this difficult to design and construct to go up in the midst of our major cities, with thousands of people inside and tens of thousands more living and working nearby. Doing so seems risky and unwise. But we allow it based on trust in the ability of the experts to manage the complexities. They in turn know better than to rely on their individual abilities to get everything right. They trust instead in one set of checklists to make sure that simple steps are not missed or skipped and in another set to make sure that everyone talks through and resolves all the hard and unexpected problems.

“The biggest cause of serious error in this business is a failure of communication,” O’Sullivan told me.

In the Citicorp building, for example, the calculations behind the designs for stabilizing the building assumed the joints in those giant braces at the base of the building would be welded. Joint welding, however, is labor intensive and therefore expensive. Bethlehem Steel, which took the contract to erect the tower, proposed switching to bolted joints, which are not as strong. They calculated that the bolts would do the job. But, as a
New Yorker
story later uncovered, their calculations were somehow not reviewed with LeMessurier. That checkpoint was bypassed.

It is not certain that a review would have led him to recognize a problem at the time. But in 1978, a year after the building opened, LeMessurier, prompted by a question from a Princeton engineering student, discovered the change. And he found it had produced a fatal flaw: the building would not be able to withstand seventy-mile-an-hour winds—which, according to weather tables,
would occur at least once every fifty-five years in New York City. In that circumstance, the joints would fail and the building would collapse, starting on the thirtieth floor. By now, the tower was fully occupied. LeMessurier broke the news to the owners and to city officials. And that summer, as Hurricane Ella made its way toward the city, an emergency crew worked at night under veil of secrecy to weld two-inch-thick steel plates around the two hundred critical bolts, and the building was secured. The Citicorp tower has stood solidly ever since.

The construction industry’s checklist process has clearly not been foolproof at catching problems. Nonetheless, its record of success has been astonishing. In the United States, we have nearly five million commercial buildings, almost one hundred million low-rise homes, and eight million or so high-rise residences. We add somewhere around seventy thousand new commercial buildings and one million new homes each year. But “building failure”—defined as a partial or full collapse of a functioning structure—is exceedingly rare, especially for skyscrapers. According to a 2003 Ohio State University study, the United States experiences an average of just twenty serious “building failures” per year. That’s an annual avoidable failure rate of less than 0.00002 percent. And, as Joe Salvia explained to me, although buildings are now more complex and sophisticated than ever in history, with higher standards expected for everything from earthquake proofing to energy efficiency, they take a third less time to build than they did when he started his career.

The checklists work.

There is a particularly tantalizing aspect to the building industry’s strategy for getting things right in complex situations: it’s that it gives people power. In response to risk, most authorities tend to centralize power and decision making. That’s usually what checklists are about—dictating instructions to the workers below to ensure they do things the way we want. Indeed, the first building checklist I saw, the construction schedule on the right-hand wall of O’Sullivan’s conference room, was exactly that. It spelled out to the tiniest detail every critical step the tradesmen were expected to follow and when—which is logical if you’re confronted with simple and routine problems; you want the forcing function.

But the list on O’Sullivan’s other wall revealed an entirely different philosophy about power and what should happen to it
when you’re confronted with complex, nonroutine problems—such as what to do when a difficult, potentially dangerous, and unanticipated anomaly suddenly appears on the fourteenth floor of a thirty-two-story skyscraper under construction. 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.

The strategy is unexpectedly democratic, and it has become standard nowadays, O’Sullivan told me, even in building inspections. The inspectors do not recompute the wind-force calculations or decide whether the joints in a given building should be bolted or welded, he said. Determining whether a structure like Russia Wharf or my hospital’s new wing is built to code and fit for occupancy involves more knowledge and complexity than any one inspector could possibly have. So although inspectors do what they can to oversee a building’s construction, mostly they make certain the builders have the proper checks in place and then have them sign affidavits attesting that they themselves have ensured that the structure is up to code. Inspectors disperse the power and the responsibility.

“It makes sense,” O’Sullivan said. “The inspectors have more troubles with the safety of a two-room addition from a do-it-yourselfer than they do with projects like ours. So that’s where they focus their efforts.” Also, I suspect, at least some authorities have recognized that when they don’t let go of authority they fail. We need look no further than what happened after Hurricane Katrina hit New Orleans.

At 6:00 a.m., on August 29, 2005, Katrina made landfall in
Plaquemines Parish in New Orleans. The initial reports were falsely reassuring. With telephone lines, cell towers, and electrical power down, the usual sources of information were unavailable. By afternoon, the levees protecting the city had been breached. Much of New Orleans was under water. The evidence was on television, but Michael Brown, the director of the Federal Emergency Management Agency, discounted it and told a press conference that the situation was largely under control.

FEMA was relying on information from multiple sources, but only one lone agent was actually present in New Orleans. That agent had managed to get a Coast Guard helicopter ride over the city that first afternoon, and he filed an urgent report the only way he could with most communication lines cut—by e-mail. Flooding was widespread, the e-mail said; he himself had seen bodies floating in the water and hundreds of people stranded on rooftops. Help was needed. But the government’s top officials did not use e-mail. And as a Senate hearing uncovered, they were not apprised of the contents of the message until the next day.

By then, 80 percent of the city was flooded. Twenty thousand refugees were stranded at the New Orleans Superdome. Another twenty thousand were at the Ernest N. Morial Convention Center. Over five thousand people were at an overpass on Interstate 10, some of them left by rescue crews and most carrying little more than the clothes on their backs. Hospitals were without power and suffering horrendous conditions. As people became desperate for food and water, looting began. Civil breakdown became a serious concern.

Numerous local officials and impromptu organizers made efforts to contact authorities and let them know what was needed, but they too were unable to reach anyone. When they finally got
a live person on the phone, they were told to wait—their requests would have to be sent up the line. The traditional command-and-control system rapidly became overwhelmed. There were too many decisions to be made and too little information about precisely where and what help was needed.