errors

Fun with confusing medication names!

February 2, 2012
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Check out this post from The Consumerist about how unhappy the FDA is with Durezol and Durasal. A hint: It’s ok if you accidentally use Durezol when you wanted Durasal, but the penalty is high for using Durasal instead of Durezol!* This link contains an explanation of the names: When drugs are submitted to the FDA for approval, the Agency carefully screens [...]

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Excerpts from the NASA ASRS

January 28, 2012
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One of my students last semester (thanks, Ronney!) turned me on the “Callback” publication from the NASA Aviation Safety Reporting System. These are almost all first person stories written as case studies of errors and accidents or near accidents. There aren’t so many that it falls under my list of neat databases, but it certainly is interesting reading. I’ve collected [...]

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What values are pilots allowed to enter for the weight of the plane?

January 22, 2012
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I’d assume when pilots enter a weight estimate for the plane prior to takeoff that there would be a decision aid to prevents gross miscalculation. It certainly seems like an undue load (no pun intended) on the pilot to require entering multiple components for weight correctly. From the article linked below I am no longer sure how much automation is [...]

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Learning to use a steering wheel with no vision or feedback

December 20, 2011
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Here is a link to an enjoyable radioshow called “99% invisible,” about the “design, architecture & the 99% invisible activity that shapes our world.”* 99% Invisible-37- The Steering Wheel This episode covers the difficulty people have in correctly miming use of a steering wheel (spoiler: they can’t!) and how they can learn to do so correctly with no visual feedback. [...]

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Paper isn’t so bad…

December 15, 2011

One thing that annoys me is the silly argument that paper is bad or paper kills. Such hollow arguments are used to encourage technology adoption in airplane cockpits, the class room, and hospitals. Usually they are associated with silly statistics about how much paper is saved or how much less weight is carried, or how much easier it will be [...]

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Rudder knob in cockpit mistaken for door latch

November 1, 2011
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Any aviation experts want to chime in about a knob turning a plane upside down? Also, please note this was characterized as “pilot error.” Pilot error causes airliner to flip, fly upside down From the article: According to the safety board, an analysis of the aircraft’s digital flight recorder indicated the co-pilot, alone in the cockpit while the captain used [...]

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Verdict Reached for Air France Rio Crash

July 29, 2011
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The BBC has reported the incident analysis of the Air France crash that killed 228 people was due to lack of pilot skill in dealing with a high altitude stall. Here is a link to the BEA Report from the Bureau d’Enquetes et d’Analyses. It’s a frightening read, as they give a moment by moment analysis of the last minutes in the cockpit. No emergency [...]

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Are we too trusting of GPS automation?

July 26, 2011
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A GPS certainly makes life easier — and although I think many of us might consider what would happen if we were without it or it was unable to identify where we were, it is less often we consider how it may lead us astray. One of our early postings on the Human Factors Blog was about a bus driver [...]

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Radiation: The Difficulty of Monitoring the Invisible – Post 2 of 2

April 27, 2011
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This post continues the list of articles on HF-related errors in radiation delivering healthcare devices. As Technology Surges, Radiation Safeguards Lag But the technology introduces its own risks: it has created new avenues for error in software and operation, and those mistakes can be more difficult to detect. As a result, a single error that becomes embedded in a treatment plan can [...]

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Radiation: The Difficulty of Monitoring the Invisible – Post 1 of 2

April 22, 2011
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Lately, I have noticed a plethora of stories on human factors mistakes with medical equipment that delivers radiation. I have collected them here for those who are interested in this problem. At times a computer bug was at fault, but often radiation overdoses came from: inadequate training (and perhaps a poor display, but those are not available for me to examine) non-transferrable mental [...]

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When poor usability costs you your job?

March 30, 2011

You may have heard that an employee who managed “social media” for Chrysler accidentally posted on Chrysler’s twitter account about *ahem* poor driving in Chrysler’s home city of Detroit. Click here for the original story. The guy who sent the tweet blames the program he used for multiple twitter accounts. The article calls it a “glitch,” which would not necessarily [...]

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Unintended Consequences of Design: Keyless Ignition Revisited

February 21, 2011
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Peter Hancock, writing in the January issue of The Ergonomist, writes about the hidden dangers imposed by rapidly advancing automotive technology (noise, vibration suppression, keyless ignition).  Noise, vibration, sound, and the mechanical key provides useful information that the car is still on.  Removing these cues could result in mode errors: In previous generations of vehicles, leaving the car ‘on’ as you [...]

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Trashcan Affordances

February 8, 2011
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The picture above shows the front and back of a trashcan designed to be lifted by machinery. This past weekend I helped my parents start to clear their home for an upcoming move and filled this trashcan to capacity. I didn’t want my mother to have to haul it to the street, so I went to go do that before [...]

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Kitchen Taskonomy Part 1: A Guest Post by Kim Wolfinbarger

January 4, 2011
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January magazines arrived a month ago, full of the annual list of ideas for organizing your house, life, office, even your car. I’ve been thinking lately about how we organize our workspaces. As Pottery Barn and Ikea entrance us with their coordinated sweater bins and modern snap-together wall-mounted organizers, how often do we ask this most important question: Do our [...]

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Children and Medication Errors – “Thanks, Mom and Dad!”

December 3, 2010
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NPR had a story this morning about the high number of medication errors children experience and some ideas as to why. In short summary: Kitchen spoons are inaccurate for giving “teaspoons” of medicine, and it doesn’t take much to give the little ones an overdose. Dose instructions are in teaspoons, but sometimes the cups that come with the bottle are [...]

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Accidental Activation During Seat Adjustment on Plane

December 1, 2010
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CNN posted this story where a co-pilot accidentally bumped a control while adjusting his seat, sending the plane into a 26 degree dive. Disaster was only averted by the pilot returning from the restroom, as apparently the co-pilot lacked the training to correct the error. From the article: The aviation agency report concluded that the 25-year-old co-pilot had not been [...]

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