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The 1982 Air Florida crash illustrates that having a safety procedure like a checklist is insufficient. The crew went through the motions, but the captain responded "off" to the "anti-ice" prompt out of habit. This lack of mindful engagement with a critical process, not the absence of the process itself, led to the disaster.
Elite performers are biased toward execution, so they rush to solve obstacles identified in pre-mortems without validating them first. This “curse of competence” creates a blind spot. The crucial first step is to “prosecute the problem”—rigorously question if the perceived obstacle is real or just an outdated assumption.
A team created a 40-item checklist to satisfy a client's specific drawing requirements. They found it too cumbersome and pared it down to the 8-10 most critical items. This "Goldilocks" checklist was powerful because it focused on high-impact areas, making compliance efficient and sustainable.
When implementing new processes to prevent errors, the new way of working must be demonstrably easier than the old one. If it adds complexity, employees will inevitably revert to the path of least resistance, negating the change.
Costolo argues against the common reaction to add process steps to prevent future mistakes, which leads to bloat like 17-page launch checklists. Instead, he advises assigning a clear DRI and managing for outcomes, not adherence to processes.
The brain's autopilot during familiar routines can cause catastrophic failures of 'prospective memory' (remembering future tasks). This explains how responsible parents can forget a child in the car when their daily drop-off routine is altered, as the dominant 'drive to work' script takes over.
Standard operating procedures (SOPs) and checklists, famously championed for reducing human error, are even more effective for AI. They provide the structured, repeatable instructions that agents need to perform tasks reliably and can be used to hold them accountable for their performance.
Experienced pilots crashed a perfectly flyable plane because overwhelming alarms caused their executive function to collapse. They fixated on one wrong idea, ignoring contradictory data—a stark warning for investors in volatile markets.
The HMHS Britannic was designed to be safer than the Titanic, but it sank faster. A minor rule violation—leaving portholes open for ventilation against standing orders—allowed water to bypass the watertight compartments after a mine strike, causing a cascading failure that doomed the ship.
When facing an existential business threat, the most effective response is to suppress emotional panic and adopt a calm, methodical mindset, like a pilot running through an emergency checklist. This allows for clear, logical decision-making when stakes are highest and prevents paralysis from fear.
If an employee makes an error while following your instructions, the instructions are flawed, not the employee. This approach shifts the focus from penalizing individuals to improving systems. It creates a better training process and a psychologically safe culture that values feedback.