The current need for enforcement of safety regulations

An NPR article reports on safety violations in Kentucky:

In December 2016, Pius “Gene” Hobbs was raking gravel with the Meade County public works crew when a dump truck backed over him. The driver then accelerated forward, hitting him a second time. Hobbs was crushed to death.

The sole eyewitness to the incident said that the dump truck’s backup beeper wasn’t audible at the noisy worksite. The Kentucky State Police trooper on the scene concurred. Hobbs might not have been able to hear the truck coming.

But when Kentucky Occupational Safety and Health arrived, hours later, the inspector tested the beeper on a quiet street and said it wasn’t a problem.

“These shortcomings are very concerning,” says Jordan Barab, a workplace safety expert who served as Deputy Assistant Secretary of Labor for Occupational Safety and Health under President Barack Obama. “Identifying the causes of these incidents is … vitally important.” Otherwise, the employer doesn’t know how to avoid the next incident, he says.

Gene Hobbs’ case is not the exception. In fact, it’s the norm, according to a recent federal audit.

Kentucky is what’s known as a “state plan,” meaning the federal Occupational Safety and Health Administration has authorized it to run its own worker safety program.

Every year, federal OSHA conducts an audit of all 28 state plans to ensure they are “at least as effective” as the federal agency at identifying and preventing workplace hazards.

According to this year’s audit of Kentucky, which covered fiscal year 2017, KY OSH is not meeting that standard. In fact, federal OSHA identified more shortcomings in Kentucky’s program than any other state.

We know that we must have regulations and enforcement of those regulations to have safe environments. Left to our own choices, people tend to choose what appears to be the fastest and easiest options, not the most safe ones. For an interesting read on the history of safety regulation, see this article from the Department of Labor.

In 1898 the Wisconsin bureau reported that it was often difficult to find safety devices that did not reduce efficiency. Sanitary improvements and fire escapes were expensive, which led many employers to resist their adoption. Constant pressure and attention were needed to obtain compliance. Employers objected to the posting of laws in their establishments and some tore them down. The proprietor of a shoe factory with very poor fire escape routes showed “a disposition to defeat” an inspector’s request for more fire escapes, though he complied in the end. A cloak maker who was also found to have inadequate fire escapes went to the extreme of relocating his operation to avoid compliance. Such delays were not uncommon.

When an inspector found abominable conditions in the dipping rooms of a match factory — poorly ventilated rooms filled with poisonous fumes from the liquid phosphorus which made up the match heads — he tried to persuade the operators to make improvements. They objected because of the costs involved and the inspector “left without expecting to see the changes made.” When a machinery manufacturer equipped his ripsaws with guards after an inspection, a reinspection revealed that the employees had removed the guards.

Without regulation, we’ll be back to 1898 in short order.

Lion Air Crash from October 2018

From CNN:

The passengers on the Lion Air 610 flight were on board one of Boeing’s newest, most advanced planes. The pilot and co-pilot of the 737 MAX 8 were more than experienced, with around 11,000 flying hours between them. The weather conditions were not an issue and the flight was routine. So what caused that plane to crash into the Java Sea just 13 minutes after takeoff?

I’ve been waiting for updated information on the Lion Air crash before posting details. When I first read about the accident it struck me as a collection of human factors safety violations in design. I’ve pulled together some of the news reports on the crash, organized by the types of problems experienced on the airplane.

1. “a cacophony of warnings”
Fortune Magazine reported on the number of warnings and alarms that began to sound as soon as the plane took flight. These same alarms occurred on its previous flight and there is some blaming of the victims here when they ask “If a previous crew was able to handle it, why not this one?”

The alerts included a so-called stick shaker — a loud device that makes a thumping noise and vibrates the control column to warn pilots they’re in danger of losing lift on the wings — and instruments that registered different readings for the captain and copilot, according to data presented to a panel of lawmakers in Jakarta Thursday.

2. New automation features, no training
The plane included new “anti-stall” technology that the airlines say was not explained well nor included in Boeing training materials.

In the past week, Boeing has stepped up its response by pushing back on suggestions that the company could have better alerted its customers to the jet’s new anti-stall feature. The three largest U.S. pilot unions and Lion Air’s operations director, Zwingly Silalahi, have expressed concern over what they said was a lack of information.

As was previously revealed by investigators, the plane’s angle-of-attack sensor on the captain’s side was providing dramatically different readings than the same device feeding the copilot’s instruments.

Angle of attack registers whether the plane’s nose is pointed above or below the oncoming air flow. A reading showing the nose is too high could signal a dangerous stall and the captain’s sensor was indicating more than 20 degrees higher than its counterpart. The stick shaker was activated on the captain’s side of the plane, but not the copilot’s, according to the data.

And more from CNN:

“Generally speaking, when there is a new delivery of aircraft — even though they are the same family — airline operators are required to send their pilots for training,” Bijan Vasigh, professor of economics and finance at Embry-Riddle Aeronautical University, told CNN.

Those training sessions generally take only a few days, but they give the pilots time to familiarize themselves with any new features or changes to the system, Vasigh said.
One of the MAX 8’s new features is an anti-stalling device, the maneuvering characteristics augmentation system (MCAS). If the MCAS detects that the plane is flying too slowly or steeply, and at risk of stalling, it can automatically lower the airplane’s nose.

It’s meant to be a safety mechanism. But the problem, according to Lion Air and a growing chorus of international pilots, was that no one knew about that system. Zwingli Silalahi, Lion Air’s operational director, said that Boeing did not suggest additional training for pilots operating the 737 MAX 8. “We didn’t receive any information from Boeing or from regulator about that additional training for our pilots,” Zwingli told CNN Wednesday.

“We don’t have that in the manual of the Boeing 737 MAX 8. That’s why we don’t have the special training for that specific situation,” he said.

Human Factors and the Ballot Box

New NPR story on the non-usability of ballots, voting software, and other factors affecting our elections:

New York City’s voters were subject to a series of setbacks after the election board unrolled a perforated two-page ballot. Voters who didn’t know they had to tear at the edges to get at the entire ballot ended up skipping the middle pages. Then the fat ballots jammed the scanners, long lines formed, and people’s ballots got soaked in the rain. When voters fed the soggy ballots into scanners, more machines malfunctioned.

In Georgia, hundreds blundered on their absentee ballot, incorrectly filling out the birth date section. Counties originally threw out the ballots before a federal judge ordered they be counted.

And in Broward County, Fla., 30,000 people who voted for governor skipped the contest for U.S. Senate. The county’s election board had placed that contest under a block of multi-lingual instructions, which ran halfway down the page. Quesenbery says voters scanning the instructions likely skimmed right over the race.

She has seen this design before. In 2009, King County, Wash., buried a tax initiative under a text-heavy column of instructions. An estimated 40,000 voters ended up missing the contest, leading the state to pass a bill mandating ballot directions look significantly different from the contests below.

“We know the answers,” says Quesenbery. “I wish we were making new mistakes, not making the same old mistakes.”

The story didn’t even mention the issues with the “butterfly ballot” from Florida in 2000. Whitney Queensbery is right. We do know the answers, and we certainly know the methods for getting the answers. We need the will to apply them in our civics, not just commercial industry.

Hawaii False Alarm: The story that keeps on giving

Right after the Hawaii false nuclear alarm, I posted about how the user interface seemed to contribute to the error. At the time, sources were reporting it as a “dropdown” menu. Well, that wasn’t exactly true, but in the last few weeks it’s become clear that truth is stranger than fiction. Here is a run-down of the news on the story (spoiler, every step is a human factors-related issue):

  • Hawaii nuclear attack alarms are sounded, also sending alerts to cell phones across the state
  • Alarm is noted as false and the state struggles to get that message out to the panicked public
  • Error is blamed on a confusing drop-down interface: “From a drop-down menu on a computer program, he saw two options: “Test missile alert” and “Missile alert.”
  • The actual interface is found and shown – rather than a drop-down menu it’s just closely clustered links on a 1990s-era website-looking interface that say “DRILL-PACOM(CDW)-STATE ONLY” and “PACOM(CDW)-STATE ONLY”
  • It comes to light that part of the reason the wrong alert stood for 38 minutes was because the Governor didn’t remember his twitter login and password
  • Latest news: the employee who sounded the alarm says it wasn’t an error, he heard this was “not a drill” and acted accordingly to trigger the real alarm

The now-fired employee has spoken up, saying he was sure of his actions and “did what I was trained to do.” When asked what he’d do differently, he said “nothing,” because everything he saw and heard at the time made him think this was not a drill. His firing is clearly an attempt by Hawaii to get rid of a ‘bad apple.’ Problem solved?

It seems like a good time for my favorite reminder from Sidney Dekker’s book, “The Field Guide to Human Error Investigations” (abridged):

To protect safe systems from the vagaries of human behavior, recommendations typically propose to:

    • Tighten procedures and close regulatory gaps. This reduces the bandwidth in which people operate. It leaves less room for error.
    • Introduce more technology to monitor or replace human work. If machines do the work, then humans can no longer make errors doing it. And if machines monitor human work, they ca
    snuff out any erratic human behavior.
    • Make sure that defective practitioners (the bad apples) do not contribute to system breakdown again. Put them on “administrative leave”; demote them to a lower status; educate or pressure them to behave better next time; instill some fear in them and their peers by taking them to court or reprimanding them.

In this view of human error, investigations can safely conclude with the label “human error”—by whatever name (for example: ignoring a warning light, violating a procedure). Such a conclusion and its implications supposedly get to the causes of system failure.

AN ILLUSION OF PROGRESS ON SAFETY
The shortcomings of the bad apple theory are severe and deep. Progress on safety based on this view is often a short-lived illusion. For example, focusing on individual failures does not take away the underlying problem. Removing “defective” practitioners (throwing out the bad apples) fails to remove the potential for the errors they made.

…[T]rying to change your people by setting examples, or changing the make-up of your operational workforce by removing bad apples, has little long-term effect if the basic conditions that people work under are left unamended.

A ‘bad apple’ is often just a scapegoat that makes people feel better by giving a focus for blame. Real improvements and safety happen by improving the system, not by getting rid of employees who were forced to work within a problematic system.

‘Mom, are we going to die today? Why won’t you answer me?’ – False Nuclear Alarm in Hawaii Due to User Interface


Image from the New York Times

The morning of January 13th, people in Hawaii received a false alarm that the island was under nuclear attack. One of the messages people received was via cell phones and it said:“BALLISTIC MISSILE THREAT INBOUND TO HAWAII. SEEK IMMEDIATE SHELTER. THIS IS NOT A DRILL.” Today, the Washington Post reported that the alarm was due to an employee pushing the “wrong button” when trying to test the nuclear alarm system.

The quote in the title of this post is from another Washington Post article where people experiencing the alarm were interviewed.

To sum up the issue, the alarm is triggered by choosing an option in a drop down menu, which had options for “Test missile alert” and “Missile alert.” The employee chose the wrong dropdown and, once chosen, the system had no way to reverse the alarm.

A nuclear alarm system should be subjected to particularly high usability requirements, but this system didn’t even conform to Nielson’s 10 heuristics. It violates:

  • User control and freedom: Users often choose system functions by mistake and will need a clearly marked “emergency exit” to leave the unwanted state without having to go through an extended dialogue. Support undo and redo.
  • Visibility of system status: The system should always keep users informed about what is going on, through appropriate feedback within reasonable time.
  • Error prevention: Even better than good error messages is a careful design which prevents a problem from occurring in the first place. Either eliminate error-prone conditions or check for them and present users with a confirmation option before they commit to the action.
  • Help users recognize, diagnose, and recover from errors: Error messages should be expressed in plain language (no codes), precisely indicate the problem, and constructively suggest a solution.
  • And those are just the ones I could identify from reading the Washington Post article! Perhaps a human factors analysis will become regulated for these systems as it has been for the FDA and medical devices.

    [humanautonomy.com] Dr. Mica Endsley: Current Challenges and Future Opportunities In Human-Autonomy Research

    We had a chance to interview Dr. Mica Endsley about her thoughts on autonomy.

    The social science research that we cover in this blog is carried out by a multitude of talented scientists across the world; each studying a different facet of the problem. In our second post in a new series, we interview one the leaders in the study of the human factors of autonomy, Dr. Mica Endsley.

    Down on the farm: Human factors psychologist Margaux Ascherl optimizes technology to make farming more efficient

    Complimenting the previous post about applied psychology, this new article dives into how one human factors PhD, Margaux Ascherl, is working to make farming more efficient with technology (she also happens to be my former student!):

    The world’s population of 7.3 billion is predicted to grow to 9.7 billion by 2050, according to the Global Harvest Initiative. To feed all those people, global agricultural productivity must increase by 1.75 percent annually.

    One person working to drive this increase is Margaux Ascherl, PhD, user experience leader at John Deere Intelligent Solutions Group in Urbandale, Iowa. John Deere recruited Ascherl in late 2012 while she was finishing her PhD in human factors psychology at Clemson University. Five years later, she now leads a team responsible for the design and testing of precision agriculture technology used in John Deere equipment.

    Ascherl spoke to the Monitor about what it’s like to apply psychology in an agricultural context and how her team is helping farmers embrace new technology to feed the world.

    Human-Robot/AI Relationships: Interview with Dr. Julie Carpenter

    Over at https://HumanAutonomy.com, we had a chance to interview Dr. Julie Carpenter about her research on human-robot/AI relationships.

    As the first post in a series, we interview one the pioneers in the study of human-AI relationships, Dr. Julie Carpenter. She has over 15 years of experience in human-centered design and human-AI interaction research, teaching, and writing. Her principal research is about how culture influences human perception of AI and robotic systems and the associated human factors such as user trust and decision-making in human-robot cooperative interactions in natural use-case environments.

    Throwback Thursday: A model for types and levels of automation [humanautonomy.com]

    This week’s Throwback Thursday post (next door, at humanautonomy.com) covers another seminal paper in the study of autonomy:

    This is our second post on our “throwback” series. In this paper, I will take you through an article written by the best in the human factors and ergonomics field, the late Raja Parasuraman, Tom Sheridan, and Chris Wickens. Though several authors have introduced the concept of automation being implemented at various levels, for me this article nailed it.

    Throwback Thursday: The Ironies of Automation [humanautonomy.com]

    My third job (in addition to being a professor, and curating this blog) is working on another blog with Arathi Sethumadhavan focused on the social science of autonomy and automation.  You can find us over here.

    Occasionally, I will cross-post items that might be of interest to both readerships.  Over there, we’re starting a new series of posts called Throwback Thursdays where we go back in time to review some seminal papers in the history of human-automation interaction (HAI), but for a lay audience.

    The first post discusses Bainbridge’s 1983 paper discussing the “Ironies of Automation”:

    Don’t worry, our Throwback Thursday doesn’t involve embarrassing pictures of me or Arathi from 5 years ago.  Instead, it is more cerebral.  The social science behind automation and autonomy is long and rich, and despite being one of the earliest topics of study in engineering psychology, it has even more relevance today.

    In this aptly titled paper, Bainbridge discusses, back in 1983(!), the ironic things that can happen when humans interact with automation.  The words of this paper ring especially true today when the design strategy of some companies is to consider the human as an error term to be eliminated

     

    Not blaming the user since 2007!

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