Complicated problems can be broken down into simple ones, with simple steps to follow but there are always unexpected issues that can arise. How are buildings constructed? There are many specialized individuals performing discrete tasks, yet you rarely hear of a building falling down. Gawande visits Joe Salvia, part of the construction firm McNamara/Salvia. Salvia has constructed skyscrapers and medical facilities. Turned off by a career in medicine requiring rote memorization, he became an engineer instead. Salvia runs through his first design job, for the roof of a building. School teaches you theoretical principles of load and stability but doesn’t teach you about cost, aesthetics, and working with other professionals. He had to keep plumbing, electrical, and mechanical engineers in the loop when designing.

Building construction used to be overseen by a Master Builder who would oversee all aspects of construction. Construction became more specialized and complex, with labor splitting into design and construction, and still further. Doctors still persist with the anachronistic paradigm of the Master Physician, which is untenable with the extreme level of specialization.

How do builders get their work done? Lots of checklists. There are delineated, daily listings of building tasks, with order of required completion, and deadline. Color coding marked critical items. The schedule was managed by computer. The lists are developed for each new building by a group representing each of the trades.

Still, there are unexpected problems, like uneven settling causing a large dimple in the floor. For these, there are “submittal schedules” specifying communication tasks, tasks that list person W will talk with person X on date Y about Z. This forces communication and quick decision making.

Salvia uses two programs to help in planning: Clash Detective and ProjectCenter. Clash Detective provides an easy view of design points where objects would collide, such as a pipe and a light fixture. This encourages communication between the plumbing and lighting specialists to work out a resolution. ProjectCenter allows anyone working on the project to notify stakeholders and update the schedule.

Finn O’Sullivan, one of Salvia’s project executives, lists communication as the biggest cause of serious error. He describes the case of the Citicorp building. The design was changed last minute to use bolted joints instead of welded ones, without informing the designer. This would have led to serious structural problems had not the designer found out and had the joints welded.