The Checklist Manifesto Read online

  For most of modern history, he explained, going back to medieval times, the dominant way people put up buildings was by going out and hiring Master Builders who designed them, engineered them, and oversaw construction from start to finish, portico to plumbing. Master Builders built Notre Dame, St. Peter's Basilica, and the United States Capitol building. But by the middle of the twentieth century the Master Builders were dead and gone. The variety and sophistication of advancements in every stage of the construction process had overwhelmed the abilities of any individual to master them.

  In the first division of labor, architectural and engineering design split off from construction. Then, piece by piece, each component became further specialized and split off, until there were architects on one side, often with their own areas of sub-specialty, and engineers on another, with their various kinds of expertise; the builders, too, fragmented into their own multiple divisions, ranging from tower crane contractors to finish carpenters. The field looked, in other words, a lot like medicine, with all its specialists and superspecialists.

  Yet we in medicine continue to exist in a system created in the Master Builder era--a system in which a lone Master Physician with a prescription pad, an operating room, and a few people to follow his lead plans and executes the entirety of care for a patient, from diagnosis through treatment. We've been slow to adapt to the reality that, for example, a third of patients have at least ten specialist physicians actively involved in their care by their last year of life, and probably a score more personnel, ranging from nurse practitioners and physician assistants to pharmacists and home medical aides. And the evidence of how slow we've been to adapt is the extraordinarily high rate at which care for patients is duplicated or flawed or completely uncoordinated.

  In the construction business, Salvia explained, such failure is not an option. No matter how complex the problems he faced in designing that first shopping mall roof, he very quickly understood that he had no margin for error. Perhaps it's the large number of people who would die if his roof collapsed under the weight of snow. Or perhaps it's the huge amount of money that would be lost in the inevitable lawsuits. But, what ever the reason, architects, engineers, and builders were forced long ago--going back to the early part of the last century--to confront the fact that the Master Builder model no longer worked. So they abandoned it. They found a different way to make sure they get things right.

  To show me what they do, Salvia had me come to see one of the construction sites where he and his team were working. His firm happened to have a job under way a short, sunny walk from his office. The Russia Wharf building was going to be a sprawling thirty-two-story, 700,000-square-foot office and apartment complex. Its footprint alone was two acres.

  The artistic renderings were spectacular. Russia Wharf was where merchant ships sailing between St. Petersburg and Boston with iron, hemp, and canvas for the shipbuilding industry once docked. The Boston Tea Party took place next door. The new glass and steel building was going up right along this waterfront, with a ten-story atrium underneath and the 110-year-old brick facades of the original Classical Revival structures preserved as part of the new building.

  When I arrived for the tour, Salvia took one look at my blue Brooks Brothers blazer and black penny loafers and let out a low chuckle.

  "One thing you learn going to construction sites is you have to have the right shoes," he said.

  The insides of the old buildings had long been gutted and the steel skeleton of the new tower had been built almost halfway up, to the fourteenth floor. A tower crane hung four stories above the structure. Ants on the ground, we worked our way around a pair of concrete mixing trucks, the cops stopping traffic, and a few puddles of gray mud to enter the first-floor field office of John Moriarty and Associates, the general contractor for the project. It was nothing like the movie construction-site field trailers I had in my mind--no rusting coffee urn, no cheap staticky radio playing, no cigar-chewing boss barking orders. Instead, there were half a dozen offices where men and women, many in work boots, jeans, and yellow safety reflector vests, sat staring into computer terminals or were gathered around a conference table with a PowerPoint slide up on a screen.

  I was given a blue hard hat and an insurance release to sign and introduced to Finn O'Sullivan, a smiling six-foot-three Irishman with a lilting brogue who served as the "project executive" for the building--they don't call them field bosses anymore, I was told. O'Sullivan said that on any given day he has between two and five hundred workers on-site, including people from any of sixty sub-contractors. The volume of knowledge and degree of complexity he had to manage, it struck me, were as monstrous as anything I had encountered in medicine. He tried to explain how he and his colleagues made sure that all those people were doing their work correctly, that the building would come together properly, despite the enormous number of considerations--and despite the fact that he could not possibly understand the particulars of most of the tasks involved. But I didn't really get his explanation until he brought me to the main conference room. There, on the walls around a big white oval table, hung sheets of butcher-block-size printouts of what were, to my surprise, checklists.

  Along the right wall as we walked in was, O'Sullivan explained, the construction schedule. As I peered in close, I saw a line-byline, day-by-day listing of every building task that needed to be accomplished, in what order, and when--the fifteenth-floor concrete pour on the thirteenth of the month, a steel delivery on the fourteenth, and so on. The schedule spread over multiple sheets. There was special color coding, with red items highlighting critical steps that had to be done before other steps could proceed. As each task was accomplished, a job supervisor reported to O'Sullivan, who then put a check mark in his computer scheduling program. He posted a new printout showing the next phase of work each week, sometimes more frequently if things were moving along. The construction schedule was essentially one long checklist.

  Since every building is a new creature with its own particularities, every building checklist is new, too. It is drawn up by a group of people representing each of the sixteen trades, including, in this case, someone from Salvia's firm making sure the structural engineering steps were incorporated as they should be. Then the whole checklist is sent to the subcontractors and other independent experts so they can double-check that everything is correct, that nothing has been missed.

  What results is remarkable: a succession of day-by-day checks that guide how the building is constructed and ensure that the knowledge of hundreds, perhaps thousands, is put to use in the right place at the right time in the right way.

  The construction schedule for the Russia Wharf project was designed to build the complex up in layers, and I could actually see those layers when Bernie Rouillard, Salvia's lead structural engineer for the project, took me on a tour. I should mention here that I am not too fond of heights. But I put on my hard hat and followed Rouillard--past the signs that said WARNING: CONSTRUCTION PERSONNEL ONLY, around a rusting nest of discarded rebar, over a trail of wood planks that served as a walkway into the building, and then into an orange cage elevator that rattled its way up the side of the skeleton to the fourteenth floor. We stepped out onto a vast, bare, gray slab floor with no walls, just twelve-foot vertical steel columns ringing the outside, a massive rectangular concrete core in the center, and the teeming city surrounding us.

  "You can see everything from here," Rouillard said, beckoning me to join him out on the edge. I crept to within three feet and tried not to dwell on the wind whipping through us or the vertiginous distance to the ground as he good-naturedly pointed out the sites along the waterfront below. I did better when we turned our backs to the city and he showed me the bare metal trusses that had been put into the ceiling to support the floor being built above.

  Next, he said, will come the fireproofers.

  "You have to fireproof metal?" I asked.

  Oh yes, he said. In a fire, the metal can plasticize--lose its stiffness and bend like s
paghetti. This was why the World Trade Center buildings collapsed, he said. He walked me down a stairway to the floor below us. Here, I could see, the fireproofing material had been sprayed on, a gypsum-based substance that made the ceiling trusses look gray and woolly.

  We went down a couple more floors and he showed me that the "skin" of the building had now been hung at those levels. The tall, shiny glass and steel exterior had been bolted into the concrete floors every few feet. The farther down we went, the more the layers had advanced. One team of subcontractors had put up walls inside the skin. The pipefitters had then put in water and drainage pipes. The tin knockers followed and installed the ventilation ducts. By the time we got down to the lowest floors, the masonry, electrical wiring, plumbing, and even some fixtures like staircase railings were all in place. The whole intricate process was astounding to behold.

  On the upper floors, however, I couldn't help but notice something that didn't look right, even to my untrained eyes. There had been rain recently and on each of the open floors large amounts of water had pooled in the same place--up against the walls of the inner concrete core. It was as if the floor were tilted inward, like a bowl. I asked Rouillard about this.

  "Yeah, the owners saw that and they weren't too happy," he said. He explained what he thinks had happened. The immense weight of the concrete core combined with the particular makeup of the soil underneath had probably caused the core to settle sooner than anticipated. Meanwhile, the outer steel frame had not yet been loaded with weight--there were still eighteen stories to be built upon it--and that's why he believes the floor had begun to tip inward. Once the steel frame was loaded, he fully expected the floor to level out.

  The fascinating thing to me wasn't his explanation. I had no idea what to make of his answer. But here was a situation that hadn't been anticipated on the construction checklist: the tilting of the upper floors. At a minimum, a water cleanup would be needed and the schedule adjusted for it. That alone could throw the builders' tidy plans off track. Furthermore, the people involved had to somehow determine whether the tilting indicated a serious construction defect. I was curious to know how they handled this question, for there was inevitable uncertainty. How could they know that the problem was just ordinary settling, that loading the steel frame would in fact level out the floor? As Rouillard acknowledged, "variances can occur." This was a situation of true complexity.

  Back down in the field office, I asked Finn O'Sullivan how he and his team dealt with such a circumstance. After all, skyscraper builders must run into thousands like it--difficulties they could never have predicted or addressed in a checklist designed in advance. The medical way of dealing with such problems--with the inevitable nuances of an individual patient case--is to leave them to the expert's individual judgment. You give the specialist autonomy. In this instance, Rouillard was the specialist. Had the building site been a hospital ward, his personal judgment would hold sway.

  This approach has a flaw, however, O'Sullivan pointed out. Like a patient, a building involves multiple specialists--the sixteen trades. In the absence of a true Master Builder--a supreme, all-knowing expert with command of all existing knowledge--autonomy is a disaster. It produces only a cacophony of incompatible decisions and overlooked errors. You get a building that doesn't stand up straight. This sounded to me like medicine at its worst.

  So what do you do? I asked.

  That was when O'Sullivan showed me a different piece of paper hanging in his conference room. Pinned to the left-hand wall opposite the construction schedule was another butcher-block-size sheet almost identical in form, except this one, O'Sullivan said, was called a "submittal schedule." It was also a checklist, but it didn't specify construction tasks; it specified communication tasks. For the way the project managers dealt with the unexpected and the uncertain was by making sure the experts spoke to one another--on X date regarding Y process. The experts could make their individual judgments, but they had to do so as part of a team that took one another's concerns into account, discussed unplanned developments, and agreed on the way forward. While no one could anticipate all the problems, they could foresee where and when they might occur. The checklist therefore detailed who had to talk to whom, by which date, and about what aspect of construction--who had to share (or "submit") particular kinds of information before the next steps could proceed.

  The submittal schedule specified, for instance, that by the end of the month the contractors, installers, and elevator engineers had to review the condition of the elevator cars traveling up to the tenth floor. The elevator cars were factory constructed and tested. They were installed by experts. But it was not assumed that they would work perfectly. Quite the opposite. The assumption was that anything could go wrong, anything could get missed. What? Who knows? That's the nature of complexity. But it was also assumed that, if you got the right people together and had them take a moment to talk things over as a team rather than as individuals, serious problems could be identified and averted.

  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.