Checklists, cognitive aids, and the future of patient safety

On Wednesday, October 30, 1935, an evaluation flight of the Boeing Model 299 was undertaken at Wright Field, northeast of Dayton, OH, USA. The Model 299 was the most technologically sophisticated aircraft of its time and was nicknamed the Flying Fortress because of the extent of its armaments. Major Ployer P. Hill was the pilot, and it was his first flight in the new aircraft. The aircraft appeared to ascend normally, but suddenly stalled, turned on one wing, and crashed, killing two of the aircraft's five crew, including Major Hill. The investigation into the crash discovered that Major Hill had omitted a crucial step during the preflight preparation; he forgot to release a catch, which on the ground locked the aircraft's control flaps.¹ Once in the air, this mistake rendered the aircraft uncontrollable. The crash investigators knew that there was probably no one better qualified to fly the new aircraft than Major Hill—his co-pilot was also highly qualified—yet despite this, the fatal error was still made. The investigators concluded that given the experience of the pilots, further training would not be an effective response to prevent such an event from happening again; a response that is very different from that which often occurs in health care when a mistake is made.² Some commentators initially believed that this meant the new aircraft was simply too complicated to fly reliably. A new approach was needed, and it took the form of a simple list of crucial tasks that must be completed before the aircraft could leave the ground. The first aviation checklist had been devised.¹ With the checklist in use, despite the aircraft's sophistication, the Model 299 (and later versions of it) performed safely for many years.

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