This article from The Conversation is a great starting point for education in information visualization, the challenges in creating clear graphs, and what an information consumer can do to understand what they are seeing.
The author is in the Geosciences, so it’s not surprising that her best example comes from that domain. The map at the top of this post flips the colors of the “landslide” areas in a way that makes it clear which areas are susceptible.
This NPR interview with Danielle Ofri, author of a new book on medical errors (and their prevention), had some interesting insight into how human factors play out during a pandemic.
Her new book is “When We Do Harm,” and I was most interested in these excerpts from the interview:
“…we got many donated ventilators. Many hospitals got that, and we needed them. … But it’s like having 10 different remote controls for 10 different TVs. It takes some time to figure that out. And we definitely saw things go wrong as people struggled to figure out how this remote control works from that one.”
“We had many patients being transferred from overloaded hospitals. And when patients come in a batch of 10 or 20, 30, 40, it is really a setup for things going wrong. So you have to be extremely careful in keeping the patients distinguished. We have to have a system set up to accept the transfers … [and] take the time to carefully sort patients out, especially if every patient comes with the same diagnosis, it is easy to mix patients up.”
And my favorite, even though it isn’t necessarily COVID-19 related:
“For example, … [with] a patient with diabetes … it won’t let me just put “diabetes.” It has to pick out one of the 50 possible variations of on- or off- insulin — with kidney problems, with neurologic problems and to what degree, in what stage — which are important, but I know that it’s there for billing. And each time I’m about to write about it, these 25 different things pop up and I have to address them right now. But of course, I’m not thinking about the billing diagnosis. I want to think about the diabetes. But this gets in the way of my train of thought. And it distracts me. And so I lose what I’m doing if I have to attend to these many things. And that’s really kind of the theme of medical records in the electronic form is that they’re made to be simple for billing and they’re not as logical, or they don’t think in the same logical way that clinicians do.”
CREATE (www.create-center.org ) is offering one on Designing for Older Adults. The workshop will present guidelines and best practices for designing for older adults. Topics include: Existing & Emerging Technologies, Usability Protocols, Interface & Instructional Design, and design for Social Engagement, Living Environments, Healthcare, Transportation, Leisure, and Work. Each participant will receive a complimentary copy of CREATE’s book Designing for Older Adults, 3rd Ed., winner of the Richard Kalish Innovative Publication Award (2019), and a USB with CREATE publications and tools.
Additional information on the workshop can be found below.
Today we present a guest post by Ragan Wilson, PhD student in Human Factors and Applied Cognitive Psychology at NC State University.
Saying that goalies in professional ice hockey see the puck a lot is an understatement. They are the last line of defense for their team against scoring, putting their bodies in the way of the puck to block shots in ways that sometimes do not seem human. In order to do that, they rely on their skills as well as their protective equipment, including chest protectors. As written by In Goal Magazine’s Kevin Woodley and Greg Balloch, at the professional level this and other equipment is being re-examined by the National Hockey League (NHL) and the National Hockey League’s Player’s Association (NHLPA).
For the 2018-2019 NHL season, there has been a change in goal-tending equipment rules involving chest protectors according to NHL’s columnist Nicholas J. Cotsonika. This rule, Rule 11.3, states that “The chest and arm protector worn by each goalkeeper must be anatomically proportional and size-specific based on the individual physical characteristics of that goalkeeper”. In practical terms, what this rule means is that goaltender chest protection needs to be size-wise in proportion to the goaltender using it so, for instance, a 185-pound goalie would seem more like a 185-pound goalie versus a 200-210 pound goalie. The reasoning for the rule change was to try to make saves by the goalie more based on ability than on extra padding and to potentially increase scoring in the league. Overall, this is a continuation of a mission for both the NHL and NHLPA to make goalie equipment slimmer, which was kick-started by changes in goalie pants and leg pads. The difference between previously approved chest protectors and the approved models are shown below thanks to the website Goalie Coaches who labeled images from Brian’s Custom Sports Instagram page below.
To a non-hockey player, the visual differences between non-NHL approved and the NHL approved pads look minuscule. However, according to In Goal Magazine, implementing these changes have been an interesting challenge for the NHL as well as hockey gear companies such as Brian’s and CCM). Whereas changing the pants rule was more straightforward, the dimensions of chest protectors are more complicated and personal to goalies (NHL). This challenge could be seen earlier in the season with mixed feedback about the new gear change. Some current NHL such as Vegas Golden Knights’ Marc-Andre Fleury (In Goal Magazine) and Winnipeg Jets’ Connor Hellebuyck (Sports Illustrated) noted more pain from blocking pucks in the upper body region. On the other hand, the Toronto Maple Leafs’ Frederik Andersen and Garrett Sparks have not had problems with these changes (Sports Illustrated).
What always makes me happy as a student of human factors psychology is when final users are made an active part of the discussion for changes. Thankfully, that is what appears to be happening so far with this rule change since the NHL and NHLPA seemed to be actively interested in and considering feedback from current NHL goaltenders about what could make them more comfortable with the new equipment standards at the beginning of the season (In Goal Magazine). Hopefully, that continues into the next season with all the rigorous, real-life testing that a season’s worth of regular and playoff games can provide. Considering there are already some interesting, individualized adjustments to the new equipment rules such as changing companies (Washington Capitals’ Braden Holtby), or adding another layer of protection such as a padded undershirt (Marc-Andre Fleury) (USA Today), it’ll be interesting what the situation is for this equipment come the next off-season, especially in terms of innovation from the companies that produce this gear at a professional level.
Ragan Wilson is a first-year human factors and applied cognitive psychology doctoral student at NC State University. She is mainly interested in the ways that human factors and all areas of sports can be interlinked, from player safety to consumer experiences of live action games.
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.
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.
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.
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
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”
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.
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.
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.
I chose a provocative title for this post after reading the report on what caused the wreck of the USS John McCain in August of 2017. A summary of the accident is that the USS John McCain was in high-traffic waters when they believed they lost control of steering the ship. Despite attempts to slow or maneuver, it was hit by another large vessel. The bodies of 10 sailors were eventually recovered and five others suffered injury.
Today marks the final report on the accident released by the Navy. After reading it, it seems to me the report blames the crew. Here are some quotes from the offical Naval report:
Loss of situational awareness in response to mistakes in the operation of the JOHN S MCCAIN’s steering and propulsion system, while in the presence of a high density of maritime traffic
Failure to follow the International Nautical Rules of the Road, a system of rules to govern the maneuvering of vessels when risk of collision is present
Watchstanders operating the JOHN S MCCAIN’s steering and propulsion systems had insufficient proficiency and knowledge of the systems
And a rather devestating:
In the Navy, the responsibility of the Commanding Officer for his or her ship is absolute. Many of the decisions made that led to this incident were the result of poor judgment and decision making of the Commanding Officer. That said, no single person bears full responsibility for this incident. The crew was unprepared for the situation in which they found themselves through a lack of preparation, ineffective command and control and deficiencies in training and preparations for navigation.
Ars Technica called my attention to an important but not specifically called out reason for the accident: the poor feedback design of the control system. I think it is a problem that the report focused on “failures” of the people involved, not the design of the machines and systems they used. After my reading, I would summarize the reason for the accident as “The ship could be controlled from many locations. This control was transferred using a computer interface. That interface did not give sufficient information about its current state or feedback about what station controlled what functions of the ship. This made the crew think they had lost steering control when actually that control had just been moved to another location.” I based this on information from the report, including:
Steering was never physically lost. Rather, it had been shifted to a different control station and watchstanders failed to recognize this configuration. Complicating this, the steering control transfer to the Lee Helm caused the rudder to go amidships (centerline). Since the Helmsman had been steering 1-4 degrees of right rudder to maintain course before the transfer, the amidships rudder deviated the ship’s course to the left.
Even this section calls out the “failure to recognize this configuration.” If the system is designed well, one shouldn’t have to expend any cognitive or physical resources to know from where the ship is being controlled.
Overall I was surprised at the tone of this report regarding crew performance. Perhaps some is deserved, but without a hard look at the systems the crew use, I don’t have much faith we can avoid future accidents. Fitts and Jones were the start of the human factors field in 1947, when they insisted that the design of the cockpit created accident-prone situations. This went against the beliefs of the times, which was that “pilot error” was the main factor. This ushered in a new era, one where we try to improve the systems people must use as well as their training and decision making. The picture below is of the interface of the USS John S McCain, commissioned in 1994. I would be very interested to see how it appears in action.