John Wayne, United Airways, and Human Factors

Most everyone probably heard about the gun accidentally fired in the passenger plan cockpit last week.

But did you hear about the designs that lead to this human error?

I had to do some detective work (and quizzing gun owners) to find the following pictures:

Here is the gun in question (or similar enough) showing the safety and the spaces in front of and behind the trigger.

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Pilots keep the gun in a hoster (see below).

Users report some difficulty ascertaining whether the gun is “locked” into the holster. If it is not, then the trigger can be in an unexpected place (namely, higher in the holster than the shaped holster seems to indicate.)

The TSA requires pilots who have been issued these guns to padlock the trigger for every takeoff and landing. Reports are that pilots do this about 10 times for a shift. Therefore, let’s assume we have 10 chances for error in using the holster and in using the padlock.

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The padlock goes through the trigger. It should go behind, to keep anyone from pulling the trigger. If the gun is 100% in the holster, this is the case. If it is not… then the padlock can end up in FRONT of the trigger. The opaque holster prevents a visual check of the trigger.

The holster also prevents a visual check of the safety.

All of this might be forgiven, or addressed with training, if it weren’t for the fact that there are numerous other ways to prevent a gun from firing rather than locking something through the trigger. Remember, we should be on the “Guard” step of “Design out, Guard, then Train.”

I’m not even going to discuss whether pilots should have guns.

“Boyd said he supports the program to arm pilots, saying, “if somebody who has the ability to fly a 747 across the Pacific wants a gun, you give it to them.”

For an amusing take, see “Trust is not Transitive.”

Educational (low-priced) laptops and cross-cultural Human Factors

In the past year, there has been an explosion of interest in the very low end of portable computing. This started with the introduction of the One Laptop Per Child project (OLPC). Quickly followed by the Asus EEE pc, Intel Classmate PC, and Everex Cloudbook. These bare bones and ultra portable laptop computers are ostensibly targeting users who would like a computer but can’t afford one. But one topic I have yet to hear about is an analysis of the usability or human factors aspects of these machines.Only the education-focused OLPC (and maybe the Classmate PC) is explicitly targeting an international, student-aged audience. Incidentally, only the OLPC has a somewhat novel interface (dubbed Sugar). The interface is dominated by pictographs with little use of text:

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OLPC screen shot

Given the extremely wide audience for these types of computers, I wonder how much work has gone into testing the usability of Sugar, or the other operating systems in these machines. In addition, given the extremely varied audience (in age, educational level, technological skill level, socio-economic status, just to name a few), does this one-size-fits-all strategy work? There has been research illustrating that even within a culture, pictograms are not universally understood.

My experience with open-source software (which all of these machines can run) has been that ease of use has never been a priority. Here is a quick visual comparison of the current machines.

Continue reading Educational (low-priced) laptops and cross-cultural Human Factors

Life imitates art (Nissan GT-R)

The new Nissan GT-R is a sports car that’s about to be released in the United States. The car has been a popular model in the Playstation game Grand Turismo. Apparently, the car’s striking information displays (the real car, not the game car) were designed by the creators of the Grand Turismo series (Polyphony Digital/Sony Computer Entertainment). Certainly fancy, but usable?

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Response to “Paper Kills”

I was reading a lengthy Q&A with Newt Gingrich in Freakonomics this morning, and came across the following:

Q: You discuss a united American front in your book. What healthcare platforms do you think Americans will unite around?

A: “… This system will have three characteristics, none of which are present in today’s system…. It will make use of information technology. Paper kills. It’s just that simple. With as many as 98,000 Americans dying as a result of medical errors in hospitals every year, ridding the system of paper-based records and quickly adopting health information technology would save lives and save money. We must also move toward e-prescribing to drastically reduce prescription errors.

Newt Gingrich is a powerful man. I am glad he is comfortable with and encouraging of technology. Me too! However, I am terrified of the assumption that information technology systems are inherently better or less error prone than paper systems. “Paper kills” is a nice, tight tag line that people are bound to remember. Is it true?

My earlier post on Paper Protocols saving lives and dollars in Michigan says otherwise. So does research in the context of medical adherence. Linda Liu and Denise Park (2004) identified a paper system as one of the most effective tested when it comes to diabetics remembering to measure their glucose.

It is not the material of the system, it is the design of the system that makes it either intuitive, fail-safe, or error prone. Blindly replacing known paper protocols and records with electronic alternatives is not a guaranteed improvement. This is the kind of thinking that brought us the touchscreen voting system.*

“Oh, it wouldn’t be blind,” one might say. I hope so, but a blanket statement such as “paper kills” doesn’t give me confidence. Paper doesn’t kill, bad design does.

I wouldn’t want to end this post without being clear: We need to stop pitting paper against computers and start solving:

1. Under what circumstances each is better

2. Why each would be better

3. How to best design for each. Paper isn’t going away, folks.

 

*The linked article mentions reliability and security without mentioning usability. I don’t want to go too far afield, so I will save my post on being unable to vote on the Georgia Flag (thanks to the compression artifacts present in the pictures, making it impossible to tell them apart.)

References:

Liu, L. L., & Park, D. C. (2004). Aging and Medical Adherence: The Use of Automatic Processes to Achieve Effortful Things. Psychology and Aging, 19(2), 318-325.

 

Usability and Signing up for Campus Safety Alerts

With recent tragic events in the United States, there has been pressure for many University campuses to install emergency alert systems. These systems notify students, faculty, and employees of emergency events via email or mobile text messages.

A few months ago, I signed up to the one offered at my University. Today, I received the following note:

You recently signed up to receive Safe alerts on your cell phone. There is some confusion about the sign-up process and you are among a group of users who did not complete the steps that will enable you to receive emergency messages on your phone. [emphasis added]

Your safety is our paramount concern, so please go to [website] to see instructions to complete the process. You will need to find the checkbox labeled “text message” to receive the CU safe alerts on your phone.

We apologize for this confusion and hope to make the sign-up process simpler in the future.

I thought this was unusual because when I initially signed up, the process did not seem overly complicated. To be sure, it was not intuitive, but not complex either. I was certain that I configured the system to send email and text alerts. I guess I was wrong (along with a few other people).

One thing that makes the system seem so apparently complex is that the system is meant to be a general purpose notification system–not just emergencies. When I log in, I see all of the classes I’ve taught, research groups I belong to, etc. organized into “Channels.” Why can’t the system be just for emergency alerts? Then the sign up process would simply involve entering my email and mobile phone number and opting-in. Instead, it looks like this:

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I suppose it has to do with some kind of cost-benefit analysis. Why pay for a system that only handles emergencies when we can extend it to general purpose messaging?

For a future post, I should talk about our new warning sirens (which I cannot hear from my office, unfortunately).

Death from Branding

If you’re Apple, you want people to see the similarities between their iPod and their iPhone. However, if you are a drug manufacturer, you do not want similarities between adult and pediatric medicine.

Above are bottles of Heparin, manufactured by Baxter Healthcare. Both blood thinners, one of these vials is 1,000 times more concentrated than the other. Confusion between these two bottles killed infants at an Indiana hospital back in 2002. This article provides a good overview of past cases.

I actually remember reading about this back then, and thought “Wow, there’s a good human factors lesson. How awful that children had to die to bring it into the spotlight.”

Unfortunately, this lesson stayed unlearned, as two more children were administered the adult drug this week. Because these were the newborn twins of Dennis and Kimberly Quaid, who have already spoken out on 60 Minutes about medication mistakes, we may see the problem addressed more thoroughly in the drug industry.

On a final note, these cases touch on the human desire to blame other humans rather than the systems they interact with. In the Indiana case, a mother who lost her child was quoted as saying:

… who blames the nurses, not drug labeling, for her daughter’s death. “I don’t think it was from the label,” she said. “They are both blue, but one is lighter than the other. How could they mistake those?”

Change blindness, automaticity, expectation, fatigue, and time pressure are but a few of the factors that might have caused the error. Sometimes, it isn’t a case of someone not just “being careful.” This is actually a good thing: we can understand and solve human factors problems. We can’t make someone care.

Unusually quiet morning radio show

What if a Radio DJ hosted a morning show and no one heard?

Lesson learned! I will try to make certain to hit ‘publish’ at the end of this post.

From the article:

“”I’ve been doing the show three days a week for 10 months and always pressed the button at the right moment. Goodness knows why I forgot this time.

“Mr Dixon, the station’s only employee, will not fire his “excellent” breakfast show DJ, who is one of 35 volunteers who have learnt their radio skills from scratch.”