Checklist

2025 January 16th

I’m an aviator, strapping into an aeroplane is something I’ve been doing since I was 19 years old. On a good day, I get to go and fly it as well. For the duration of the hour or so between strapping into an aeroplane and unstrapping again at the end of the flight, I have one overwhelming desire. Not to screw up and break something. However skilled I might happen to be - and allegedly I’ve a bit of skill in the game of aviation, I need a bit of help in this. And we’ve a technology developed since sometime around 1940 to help us all with this - it’s called a checklist.

There are a few misguided souls who think that this is de-skilling the task of flying an aeroplane, as if it’s somehow cheating. I have a term for those people - it is “idiots”. Yes, I can *probably* get everything right on a flight, from memory, without using a checklist, but every time, for hundreds of flights? Not a chance. Sooner or later I’ll make a slip, it might be embarrassing, it might be trivial, it might be forgetting to put the wheels down before landing.

The number of occasions proper checklist use saved my neck, or at the least me from embarrassment, is so many I lost count decades ago.

The checklist above is the one we use on one of my syndicate aeroplanes, and it’s a straightforward list of key actions needed at different parts of the flight. If might not be obvious but there are actually three different ways we can use this, and which is right will depend upon circumstances…

(1) READ-DO. This is pretty self explanatory, you work down the checklist, and do each action as you come to it.

(2) DO-CONFIRM. This is where you just do the things you need to do, then in a spare moment, get the checklist out, read down it, and double-check you didn’t miss anything.

(3) CHALLENGE-RESPONSE. We don’t use this all that much in the single pilot aeroplanes I usually fly, but it’s where person A tells person B to do something, B then responds confirming they’ve done it.

All of them have a place, but it’s important to know which you’re doing at any time. For me, personally I read-do from the checklist most of the time on the ground, and in the air I mostly use a mental mnemonic to do the same: then if I’m ever uncertain I can whip the checklist out to either read-do where I’ve had a brain fart, or confirm I didn’t miss something when I’ve a spare moment.

You’ll notice that I’ve showed three ways to use a written checklist, and a fourth way to use mnemonics. I mentioned the I’M SAFE pre-flight pilot fitness checklist the other day, which is another mnemonic. When I first learned to fly microlights - pretty much all very windy open cockpits back then, mnemonics were the norm, and we memorised them - but then many sensible people had them printed on a card or dyno-taped into the cockpit anyhow.

Sometimes we add in another concept of flow drills, these were much loved when I got to fly military aircraft occasionally. This requires a fair bit of familiarity - look at the Phantom cockpit below, for example, and a pilot in a hurry might have started at the right of the cockpit, and just run over all of the dials and controls in the order he came to them, using that to remember if he had to do something with it, for, say, his pre-start checks on a fighter scramble. I still use and teach that practice myself particularly for dealing with the initial actions of an in-flight emergency, and know from first hand experience it works - even if I’ll always still have the paper checklist there if (or when!) I need it to make sure I didn’t miss anything important.

So what, you are shouting at the screen by now, the hell has this got to do with cancer? Well let me introduce you to a very clever man called Atul Gawande, a Boston, Massachussets based research surgeon, now something senior in the US government but who used to work part time for the World Health Organisation. Some years ago he led a project to look at the possibility of adapting aviation checklist practices to surgery. He wrote about that journey in a book, The Checklist Manifesto, as well as a few research papers. He discovered that the way we do things in aviation didn’t work in medicine without a few major changes, but his team eventually came up with something called the Surgical Safety Checklist.

And it works, really really works. It has proved to be really successful in eliminating any number of rare errors. And they can be rare - but let’s say it saves a stupid mistake in 1 patient in a thousand, but that operation is done around ten thousand times a year (roughly the number of prostatectomies in the UK), and you just saved ten people from possibly lifechanging injuries.

Of course, just like in aviation, they’re only as good as the professionalism of the person using the checklist. I’ve often had to pick up student pilots who have slipped into “confirmation bias” where they repeat the right words, but don’t actually do the right things. Everybody needs to watch themselves for that.

The NHS adapted the checklist to suit its own preferred ways of working - and whether you realise it or not, you’ve almost certainly had it used on you. Been repeatedly asked what you’re there for?, or your date of birth?, or whether you have any allergies? Welcome to the NHS checklist family. A bit of minor administrative nauseum that’s all for your own good, so don’t complain!

I’ve been adapting this to my own cancer care, and here’s the most obvious instance. I bought this for a tenner online - a stack of multicoloured boxes, divided into four daily doses. I’ve got into a habit of carefully filling it with the dosage sheet and all the blister packs once a week. Then the rest of the week, I can just use it to simply and easily make sure I take the right pills, at the right time, of the 174 I’m scheduled to take each 21 day chemo cycle (195 if you add in a daily multivitamin). Both the effort saving, and the removal of risk of error, are really obvious.

Checklists can be boring and unglamorous; sometimes arrogant professionals consider them to be patronising and demeaning of their professionalism. But they bloody work! Consider how you can use them in your own self care (or just your holiday packing!), and when you get asked a simple question for the sixth time that day - don’t complain, it’s for really sound safety reasons, and absolutely for your own benefit.