After the failure of the initial checklist, Gawande researches flight checklists and how they are made. He contacts Daniel Boorman, a checklist developer for Boeing. Daniel explains how flight checklists are divided into normal and non-normal lists, and runs through one of the non-normal checklists with Gawande in a flight simulator. This “DOOR FWD CARGO” checklist was developed an accident with a cargo door blowout, before the cause was even known. Luckily, the next time the DOOR FWD CARGO light came on, there was a checklist handy for the problem.

There are several important checklist considerations:

• Pause points (below 90 seconds)
• 5-9 items (depending on context)
• Simple, precise wording
• Use professional jargon
• Limit to 1 page
• DO-CONFIRM v READ-DO
  • DO-CONFIRM – jobs performed, then stopped
  • READ-DO – tasks marked as completed