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Roundup of Human Error in the News

Human error leads to the grounding of Discovery Shuttle
Reports coming out of NASA suggest that the foam section which fell of Discovery during its launch in July was due to human error. Workers may have destroyed the foam section around Discovery’s fuel tank by accident leading to significant safety concerns for the crew and a complete grounding of the Shuttle program.
Full story


Bermuda suffers costly human error
The island of Bermuda suffered a fire and an island wide black out for three days as a result of human error in July. The cost of the error is estimated at $5 million. According to the article, three events triggered by human error conspired to cause the problem: “Failure within a piece of switchgear; the failure of some back-up systems designed to prevent the initial failure from having any impact, and a fire suppression system that did not work because it had been disabled.”
Full story

Human error blamed for all New York Subway derailments
A recent report (although the article doesn’t say which one) suggests that all new york subway derailments in the past 20 months were caused by human error. One incident was caused by the driver falling asleep. Although no one was seriously hurt in the incidents, the report suggests that most of the incidents were caused by workers and supervisors breaking rules. It would seem that it is only a matter of time before a more serious event takes place unless the subway authority acts quickly.
Full story

Climate of fear makes human error reassuring

September 12th Los Angeles was the latest high profile case of human error. According to the various news reports, a major power outage lasted several hours leaving people trapped in elevators and motorists gridlocked. Reports suggest that the cause of the afternoon blackout in LA was due to utility workers cutting several cables by mistake.

Many residents were initially concerned that something more sinister was responsible especially as the city had received warnings of possible terrorist action the day before, on the anniversary of 9/11.

In the days of terrorist threats and major natural disasters the presence of human error can be of some comfort. The heightened state of fear in the US and the UK leads people to panic when things go wrong, but when we find that the cause is simply down to a mistake, fear is replaced by a sense of relief. The fact that ‘we are only human’ means that we are all used to making mistakes and tend to accept that they are somewhat inevitable. I wonder however that the current climate of fear may make us more accepting of human error, that error becomes an expected flaw and therefore is less important to minimize it. The transport industry (especially air & rail), the armed forces, the nuclear and oil industries will hopefully still strive to reach safety goals in minimizing human error in operation, however I wonder if everyone else in society will become more complacent and perhaps not so interested in avoiding error themselves.

Article which stimulated these thoughts

Subverting from within - a great guide to influencing UCD change

Anyone who has worked in a company as a sole usability person or has been surrounded by people who just don't get the whole user-centred design thing will know just how frustrating it can be. If you are anything like me, and you find it hard not to get upset when people either totally disregard the needs of users, or are totally unware who their users even are, then you know what its like.

A fantastic article from 'Creating Passionate Users' sets out the tools and techniques you need to 'subvert from within' to start changing the culture and mindset within the company. For example, the article suggests that you should question everything in terms of its benefits to users. It also suggests that you adopt a slightly confused, mildly annoyed look when people don't think about things from a user's perspective. A friend of mine I worked with at the BBC perfected this look. It was a head to one side frown and half smirk which seemed to stop people dead mid-conversation when they noticed it.

For anyone wishing to make a difference and get people thinking about users, this is an excellent place to start. Good luck, you'll probably need it!

Full article

Why software sucks (and what to do about it)

When I fist started out as a Usability 'expert', it always left me dubfounded when I was presented with a piece of software or a website which was designed so badly. I just couldn't understand how someone had been so shortsighted. I got on my high horse, condemned it and pointed out all its faults without really offering any solutions. It wasn't until I worked more closely with designers and actually started to create things that I realised just how hard it was to design something that didn't suck. Only then was I able to actually start making a difference and help design good products.



'Why software sucks (and what to do about it)' is a great article from Scott Burkun which crystalises the issues surrounding why designs can suck, and how to go about making stuff that is a lot less sucky. He manages to pull in lots of different perspectives on design and human factors into an article which delivers some pertinant points in a clear and entertaining way.

Full article

Oh the irony

This photo was taken at Heathrow Airport in an attempt to avoid erorrs being made with aircraft taxiing to the wrong places and causing runway incursions (when something infringes a runway without warning).

The Psychology of... compulsive shopping

Compulsive buying disorder, according to New York psychologist Lane Benson, is when a person regularly buys things out of a desire to be more like an ideal image of themselves, rather than an actual need for a product. I think we're probably all guilty of that from time to time, but Lane argues that "It's only a problem if it leads to significant impairment in some aspect of your life - financial, emotional, social, occupational, or spiritual,".

This is an interesting article which may have many boyfriends nodding in despair recognising the similarities in their girlfriend's behaviour. I especially love the quote "You can never get enough of what you really don't need" which I'm sure is my girlfriend's motto.

Full article here

Human Error: the movie

Well I suppose it had to happen sometime, a film titled Human Error. But not just any film, its a "post-industrial, pre-apocalyptic, existential comedy". So its not one of those 'it does what it says on the tin' kind of films ;)

Human Error premieres today, September 16, at New York’s Landmark Sunshine Theater.

If anyone actually goes to see it, I'd be interested to hear what a post-industrial, pre-apocalyptic, existential comedy actually is.

More information here

Neglect usability - at what cost?

So you've got loads of money, you've invested in several companies and you're an extremely busy businessperson. You want to check out the annual reports of the companies you have financial interest in, but they are poorly designed so you can't find what you're looking for, you get frustrated and leave. Does this affect your perception of the company ? You bet it does.

Companies are all too happy to get investers and shareholders but it would seem that they are neglecting the needs of their lifelines by forgetting about basic usability principles when displaying company reports. A recent study suggests that less than 10% of some of the worlds biggest 100 companies are falling short of basic usability pricinples in their annual reports. It would be very interesting to know at what cost

More here
Full survey here

Great ipod Nano review

Ok, so I think this will have to live under the Vaguely related randomness category, but I just had to show you this review of the ipod Nano.

The review takes you through the whole user experience of buying a new ipod Nano, from taking it out of the box to running it over with your car! Yes thats right, they take a brand new Nano, play with it, admire it and then destroy it.


Great review for a great product.

ipod Nano Review

Sobering report on human factors issues leading to a midair collision

In this paper, we provide an analysis of the event, highlighting fundamental human and system errors that occurred that night: errors that contributed to the worst midair collision in recent history

This is an excellent summary of the key issues to be learned from this disaster. There has been a number of changes to Eurpoean air traffic operations to try to address these issues, but as usual the human related issues are (arguably) the hardest to deal with.

The report suggests that a number of system and human 'errors' combined to produce the midair collision. Some of the key human factors issues highlighted are:

- issues surrounding divided attention
- trust in automation
- decision making in time pressured situations

When I get more time, I'll expand on these and bring you a little more insight into the complexity surrounding each issue.
Full 4 page report
Orignial news reports of the crash

A beautiful tale of experience design

Beautifully designed, thoroughly researched and eloquently communicated... and that’s just the case study write up.

Something we always meant to do when working at the BBC was to document our process and take people through a visual story of what the project was trying to solve and how we researched, planned, designed and delivered the final solution. That is exactly what Mark Rettig and Aradhana Goel have done. They have provided extensive detail on how they went about redesigning an entire library to better serve the needs of its users.

For anyone who doesn't have much experience of good user-centred design at work you'll learn buckets from this. For anyone who has lost of experience, you'll wish you documented it like they have.

Excellent stuff!

Related links:

The PDF file

http://www.fitassociates.com

http://www.maya.com

Football authorities take a step closer to mitigating human error

Finally the powers that be in Football have taken a step forward to help eliminate human error.

Pundits and managers have been calling for goal line technology for a while, and only last season we saw two classic cases of human error having a significant effect on the fortunes of two premiership clubs. Mendes' shot on goal which caught Roy Carrol off guard, letting the ball cross the line by some distance before he quickly recovered and pretended nothing had happened, and the debatable goal given to Liverpool against Chelsea in the Champions League semi-final.

The Spurs v Man United game ended in a 0 – 0 draw. If not for human error from the linesman and the ref, Spurs probably would have won the game giving them a vital 3 points which could have resulted in a European place. Similarly, the debatable goal awarded to Liverpool resulted in Chelsea missing out on the Champions League final. Although not so clear cut as the Mendes goal, it is still an item for some debate and the uncertainty is extremely painful for Chelsea fans to bear.

Although uncertainty will never be taken away from the game completely (after all we are only human and we will make mistakes), a relatively simple technological solution is available to clear up the ‘was it a goal?’ debate in matches. Fifa president Sepp Blatter indicated that the new goal line technology would be trialled at the under 17 world championships and if successful it will be used in the 2006 world cup in Germany.

The technology involves a chip inside the ball and sensors along the goal line. As soon as the ball passes the line, a buzzer alerts the referee which eliminates the chance for human error. This move to taking tasks away from the human and assigning them to technology is a very common way to mitigate human error, and comes at various levels from taking the human out of the loop completely, to assisted control where the human is in control but the computer responds to requests from the human. The goal line technology suggested here is a more watered down version which aids the human in making decisions.

In comparison to other sports, the football authorities have been slow to introduce mitigation against human error. Athletics have been using digital precision timing for some time to avoid human error misjdgements leading to lesser atheletes being given unfair awards. In tennis, the cries of “you cannot be serious man, it was in” are long gone with the introduction of Hawk-Eye technology to leave umpires with little confusion over whether a ball was inside or outside of the line.

Some people argue that human error is part of the drama of sports, and the more technology is introduced, the more boring and clinical the game will get leaving people nothing to talk about in the bars afterwards. Although this argument may have some weight, it is unlikely that football will ever remove human error from referee decisions entirely and the introduction of video replay consultation still seems a long way off.

As a Chelsea fan, I can wholeheartedly say that we would have been in the Champions League final in May 2005 if it wasn’t for human error. In my job I regularly try to mitigate human error, so I am right behind new ways which attempt to minimise the negative effects from our almost inevitable human errors.


Related Links:

Fifa introduces goal line technology

More information on automation

Hawk-eye article

Worlds worst refereeing decisions

Insight into Intel's user-centred design activities

Interesting article describing Intel's use of anthropologists and social scientists to help them improve their innovation and product design. A good example of a top company following and advocating a good UCD process

ZDnet article

Car ergonomics: Driving causes health problems

There seems to be a lot of human factors issues concering car use lately. Here's another article to add to the mix which highlights a rise in health issues arising from driving posture.

“Driving long distances is one of the worst things you can do to your body,” says Brian McIlwraith, an osteopath who specialises in car ergonomics. “There’s a tendency for you to be forced into a slumped position, so your back is bent, putting pressure on the hips, lower back and intervertebral discs.

The best car ergonomics according to the Times artcile are:

1. Volvo V70
2. Mercedes S-class
3. Lexus LS 430
4. Peugeot 607
5. Renault Modus /Nissan Micra

Times Online article

Research suggests even driving using hands-free mobiles is dangerous

New research coming out of the University of Illinois suggests that a driver’s ability to keep the car at a fixed speed within a single lane of traffic is impaired when talking and listening on a hands-free mobile phone. This adds even further weight to arguments from organisations like the Royal Society for the Prevention of Accidents calling for a complete ban on the use of mobile phones when driving. Recent legislation in the UK has been introduced to stop drivers from using hand held mobile phones while driving, but they have fallen short of pushing for a complete ban.

However the body of research and expert opinion supporting the view that even hands-free use of mobile phones has a detrimental effect on cognitive ability is growing. In November 2004, the University of Illinois carried out a different study which found that drivers using hands-free phones

young and old – struggled to see dangerous scenarios appearing in front of them.

The problem with talking and listening using a hands-free phone, according to Donald Norman a well respected cognitive scientist and human-centred design visionary, is to do with the demands placed upon the driver to be in two different places

When you are on a telephone call, you are doing a very special sort of activity, for you are a part of two different spaces, one where you are located physically, the other a mental space, the private location within your mind where you interact with the person on the other end of the conversation. This mental partitioning of space is a very special facility and it makes the telephone conversation, unlike other joint activities, demanding a special kind of mental concentration.

Norman goes on to suggest:

The part of driving that suffers is the reflective oversight, the planning, the ability to anticipate the actions of other drivers and any special conditions of the environment. That you can still appear to drive normally blinds you to the fact that the driving is less skillful, less able to cope with unexpected situations. Thus, the driving becomes dangerous, the cause being that distracting mental space.

Seeing as drivers in the UK appear to be ignoring the law against hand held use, I wonder how long it will be before we see a full ban on driving using mobile phones actually working. In the meantime, I’ll be keeping a keen eye on the causes cited in the road accident statistics.

Related Links:

Illinois August 2005 research
Royal Society for the Prevention of Accidents
Norman’s article
Illinois November 2004 research
BBC News reporting drivers ‘ignoring mobile rules’

Ergonomics in the kitchen

When I finally get around to remodelling my kitchen, I'm looking forward to applying some good ergonomics principles to the layout and positioning of work spaces and utilities, because my current layout drives me nuts. The sink is too low for me, the cupboards are too high for my girlfriend and the movement between the cooker, sink, and fridge is cumbersome, especially when the cat sits in the middle of the floor.

I found this article earlier and thought it might be useful for anyone brave enough to start designing a new kitchen. Although fairly short and sweet, there are some good nuggets of information in it:

"taller people (5'- 5" and above) would feel comfortable working with a 10" deep sink, smaller persons (5'- 0") could be at greater ease with 8" deep sinks"

Full Article

What the hell is Human Factors?

Whoa Nelly, hold up, you’re going too fast

Ok, maybe I’ve jumped the gun a bit. Let me try and break down this tricky little sucker for you.

Human Factors, as the name kind of suggests, focuses upon the human within a system. A system can be anything from the more simple ones like a kettle, or your computer workstation, to much more complex ones like the cockpit of a plane or a nuclear reactor control room. In general, a Human Factors person will look at all aspects of the human’s interaction with the system in an attempt to make sure the system takes into account human strengths and weaknesses.

Part of the reason that the term Human Factors is so difficult to break down is because it is a collection of specialisms including cognitive psychology, ergonomics, human-computer interaction, occupational psychology and safety. I’ll break these terms down individually another time.

Now, I’m not sure if that made a lot of sense to you so let me try an example. Take the design of a new emergency services call centre. Human Factors people would be called in to help design the room layout to determine the best position for desks to facilitate communication amongst teams. They may also be involved in selecting appropriate office furniture taking into account ergonomic requirements. Once the control room is designed, they may look at working procedures, the design of any software and hardware to be used by the operators, and possibly how to train users appropriately.

As you can see that’s quite a lot of work and a hell of a lot of knowledge needed therefore very few people can provide all those skills. So to be a human factors person, or even interested in it, you will always need to learn more, and that’s where this blog comes in. I'll try to pick out all the interesting and relevant news, articles, comment and essays from all the specialist areas that make up Human Factors. If there's anything specific you want me to focus on, let me know.

Microsoft's healthy computing guide

Ergonomics

When you think of Microsoft's relationship with its users, its easy to think of a money grabbing, uncaring relationship. But there are times, although not many, when they really do try to do something nice. Ahhh

Here's a pretty good simple guide to workstation ergonomics, with some pretty good tips for maintaining a healthy workstation

More of the same please Mr Gates

http://www.microsoft.com/hardware/hcg/default.html

It's started...

Well here we go. Another new blog to add to the millions already out there. Apparently every second a new blog is created (http://news.bbc.co.uk/1/hi/technology/4737671.stm) which does beg the question:

So what makes this one any different?

As far as I can tell, there's not that many sites out there which talk about human factors as a whole. Sure there are sites covering usability, human-computer interaction, psychology, ergonomics and so on, but few which pull them all together.

So thats what I'm gonna try to do - Pull all the human factors news, information, comment and research together in one place for anyone who's interested in this kind of stuff.

Wish me luck, I think I might need it.