The Checklist Manifesto by Atul Gawande Page B

you push the power of decision making out to the periphery and away from the center. You give people the room to adapt, based on their experience and expertise. All you ask is that they talk to one another and take responsibility. That is what works.
    The strategy is unexpectedly democratic, and it has become standard nowadays, O’Sullivan told me, even in building inspections. The inspectors do not recompute the wind-force calculations or decide whether the joints in a given building should be bolted or welded, he said. Determining whether a structure like Russia Wharf or my hospital’s new wing is built to code and fit for occupancy involves more knowledge and complexity than any one inspector could possibly have. So although inspectors do what they can to oversee a building’s construction, mostly they make certain the builders have the proper checks in place and then have them sign affidavits attesting that they themselves have ensured that the structure is up to code. Inspectors disperse the power and the responsibility.
    “It makes sense,” O’Sullivan said. “The inspectors have more troubles with the safety of a two-room addition from a do-it-yourselfer than they do with projects like ours. So that’s where they focus their efforts.” Also, I suspect, at least some authorities have recognized that when they don’t let go of authority they fail. We need look no further than what happened after Hurricane Katrina hit New Orleans.
    At 6:00 a.m., on August 29, 2005, Katrina made landfall inPlaquemines Parish in New Orleans. The initial reports were falsely reassuring. With telephone lines, cell towers, and electrical power down, the usual sources of information were unavailable. By afternoon, the levees protecting the city had been breached. Much of New Orleans was under water. The evidence was on television, but Michael Brown, the director of the Federal Emergency Management Agency, discounted it and told a press conference that the situation was largely under control.
    FEMA was relying on information from multiple sources, but only one lone agent was actually present in New Orleans. That agent had managed to get a Coast Guard helicopter ride over the city that first afternoon, and he filed an urgent report the only way he could with most communication lines cut—by e-mail. Flooding was widespread, the e-mail said; he himself had seen bodies floating in the water and hundreds of people stranded on rooftops. Help was needed. But the government’s top officials did not use e-mail. And as a Senate hearing uncovered, they were not apprised of the contents of the message until the next day.
    By then, 80 percent of the city was flooded. Twenty thousand refugees were stranded at the New Orleans Superdome. Another twenty thousand were at the Ernest N. Morial Convention Center. Over five thousand people were at an overpass on Interstate 10, some of them left by rescue crews and most carrying little more than the clothes on their backs. Hospitals were without power and suffering horrendous conditions. As people became desperate for food and water, looting began. Civil breakdown became a serious concern.
    Numerous local officials and impromptu organizers made efforts to contact authorities and let them know what was needed, but they too were unable to reach anyone. When they finally gota live person on the phone, they were told to wait—their requests would have to be sent up the line. The traditional command-and-control system rapidly became overwhelmed. There were too many decisions to be made and too little information about precisely where and what help was needed.
    Nevertheless, the authorities refused to abandon the traditional model. For days, while conditions deteriorated hourly, arguments roared over who had the power to provide the resources and make decisions. The federal government wouldn’t yield the power to the state government. The state government wouldn’t give it to the local government. And no one