Institutional Memory, Culture, & Disaster

I admit a fascination for reading about disasters. I suppose I’m hoping for the antidote. The little detail that will somehow protect me next time I get into a plane, train, or automobile. A gris-gris for the next time I tie into a climbing rope. Treating my bike helmet as a talisman for my commute. So far, so good.

As human factors psychologists and engineers, we often analyze large scale accidents and look for the reasons (pun intended) that run deeper than a single operator’s error. You can see some of my previous posts on Wiener’s Laws, Ground Proximity Warnings, and the Deep Water Horizon oil spill.

So, I invite you to read this wonderfully detailed blog post by Ron Rapp about how safety culture can slowly derail, “normalizing deviance.”

Bedford and the Normalization of Deviance

He tells the story of a chartered plane crash in Bedford, Massachusetts in 2014, a take-off with so many skipped safety steps and errors that it seemed destined for a crash. There was plenty of time for the pilot stop before the crash, leading Rapp to say “It’s the most inexplicable thing I’ve yet seen a professional pilot do, and I’ve seen a lot of crazy things. If locked flight controls don’t prompt a takeoff abort, nothing will.” He sums up the reasons for these pilot’s “deviant” performance via Diane Vaughn’s factors of normalization (some interpretation on my part, here):

  • If rules and checklists and regulations are difficult, tedious, unusable, or interfere with the goal of the job at hand, they will be misused or ignored.
  • We can’t treat top-down training or continuing education as the only source of information. People pass on shortcuts, tricks, and attitudes to each other.
  • Reward the behaviors you want. But we tend to punish safety behaviors when they delay secondary (but important) goals, such as keeping passengers happy.
  • We can’t ignore the social world of the pilots and crew. Speaking out against “probably” unsafe behaviors is at least as hard as calling out a boss or coworker who makes “probably” racist or sexist comments. The higher the ambiguity, the less likely people take action (“I’m sure he didn’t mean it that way.” or “Well, we skipped that list, but it’s been fine the ten times so far.”)
  • The cure? An interdisciplinary solution coming from human factors psychologists, designers, engineers, and policy makers. That last group might be the most important, in that they recognize a focus on safety is not necessarily more rules and harsher punishments. It’s checking that each piece of the system is efficient, valued, and usable and that those systems work together in an integrated way.

    Thanks to Travis Bowles for the heads-up on this article.
    Feature photo from the NTSB report, photo credit to the Massachusetts Police.

    Thoughtful and Fun Interfaces in the Reykjavik City Museum

    I stopped over in Iceland on the way to a conference and popped in to the Reykjavik City Museum, not knowing what I’d find. I love the idea of technology in a museum, but I’m usually disappointed. Either the concepts are bad, the technology is silly (press a button, light some text), or it just doesn’t work, beaten into submission by armies of 4-year-olds.

    Not at the Settlement Exhibit in Reykjavik. There are two unique interfaces I want to cover, but I’ll start at the beginning with a more typical touchscreen that controlled a larger wall display. As you enter the museum, there are multiple stations for reading pages of the Sagas. These are the stories of their history, from the 9th to 11th centuries, and beautifully illustrated.
    njals_saga_miniature
    They have been scanned, so you can browse the pages (with translations) and not damage them. I didn’t have all day to spend there, but after starting some of the Sagas, I wished I had.

    Further in you see the reason for the location: the excavation of the oldest known structure in Iceland, a longhouse, is in the museum! Around it are typical displays with text and audio, explaining the structure and what life was like at that time.

    Then I moved into a smaller dark room with an attractive lit podium (see video below). You could touch it, and it controlled the large display on the wall. The display showed the longhouse as a 3-D virtual reconstruction. As you moved your finger around the circles on the podium, the camera rotated so you could get a good look at all parts of the longhouse. As you moved between circles, a short audio would play to introduce you to the next section. Each circle controlled the longhouse display, but the closer to the center the more “inside” the structure you can see. Fortunately, I found someone else made a better video of the interaction than I did:

    The last display was simple, but took planning and thought. Near the exit was a large table display of the longhouse. It was also a touch interface, where you could put your hand on the table to activate information about how parts of the house were used. Think of the challenges: when I was there, it was surrounded by 10 people, all touching it at once. We were all looking for information in different languages. It has to be low enough for everyone to see, but not so low it’s hard to touch. Overall, they did a great job.

    Be sure to do a stopover if you cross the Atlantic!

    Both videos come from Alex Martire on YouTube.