Category Archives: errors

Product Confusability: Tide Pods

Kim Wolfinbarger sends along a new case of dangerous things being confused for food (the story is the same but the actors different, see previous examples).  Before you reflexively say, “only an idiot would confuse the two,” remember that 5-year olds don’t know the difference.  First rule of HF-club: you are not the user (or victim):

In California alone, 307 cases of accidentally ingestion of laundry packs by young children have been reported this year. And the cases in California, and nationwide, aren’t just limited to toddlers snarfing Tide Pods. When the product was released, Tide rivals such as All and Purex launched their own single-dose detergent capsules as well. Earlier this summer, Tide reconfigured the packaging of the product, adding a double-latched lid to the plastic tubs containing the Pods to make it more difficult for children to tamper with. Still, the number of reported incidents continues to climb along with news stories warning parents to take caution.

Just yesterday, Consumer Reports reported on a wave of Tide Pod-related poisonings in Glasgow, Scotland while the New York Daily News published a quick article stating that in New York City alone, 40 children have been hospitalized after eating the packs since April. TODAY also just published a piece on the alarming trend in which Ken Wahl, medical director for the Illinois Poison Center states: “I’ve never seen a consumer product that had that degree of injury in a child.”
Dishwashing detergent also comes in pod-like single serving doses but I am not aware of similar cases of ingestion.  Maybe it’s the coloring (they tend to be blue/green) or size (they are a bit larger I think)?

Everyday Automation: Auto-correct

This humorous NYT article discusses the foibles of auto-correct on computers and phones. Auto-correct, a more advanced type of the old spell checker, is a type of automation. We’ve discussed automation many times on this blog.

But auto-correct is unique in that it’s probably one of the most frequent touchpoints between humans and automation.

The article nicely covers, in lay language, many of the concepts of automation:

Out of the loop syndrome:

Who’s the boss of our fingers? Cyberspace is awash with outrage. Even if hardly anyone knows exactly how it works or where it is, Autocorrect is felt to be haunting our cellphones or watching from the cloud.

Trust:

We are collectively peeved. People blast Autocorrect for mangling their intentions. And they blast Autocorrect for failing to un-mangle them.

I try to type “geocentric” and discover that I have typed “egocentric”; is Autocorrect making a sort of cosmic joke? I want to address my tweeps (a made-up word, admittedly, but that’s what people do). No: I get “twerps.” Some pairings seem far apart in the lexicographical space. “Cuticles” becomes “citified.” “Catalogues” turns to “fatalities” and “Iditarod” to “radiator.” What is the logic?

Reliance:

One more thing to worry about: the better Autocorrect gets, the more we will come to rely on it. It’s happening already. People who yesterday unlearned arithmetic will soon forget how to spell. One by one we are outsourcing our mental functions to the global prosthetic brain.

Humorously, even anthropomorphism of automation (attributing human-like characteristics to it, even unintentially)! (my research area):

Peter Sagal, the host of NPR’s “Wait Wait … Don’t Tell Me!” complains via Twitter: “Autocorrect changed ‘Fritos’ to ‘frites.’ Autocorrect is effete. Pass it on.”

(photo credit el frijole @flickr)

String of Workplace Incidents Lead to Death

A restaurant owner was found deceased in a walk-in cooler, but not for reasons one might expect. You can read the full article here, and I’ll provide a quick summary below.

  • An electrical outage prompted the restaurant to fill the cooler with dry ice to prevent spoilage
  • The button for exiting the cooler from the inside had been broken for some time
  • One of the owners went to check on the food at an unusual time, because he was worried it might be spoiling
  • No one was scheduled to be at the restaurant for many hours after his visit, which was closed due to the power outage
  • He triggered an alarm, but police treated it as a false alarm when the restaurant appeared closed and locked
  • He was overcome by the carbon dioxide fumes when he could not exit the cooler and died

The case includes:

  • A minor incident (power outage) prompting unusual behavior (use of dry ice, checking on the food in the evening)
  • Failure to maintain safety equipment (the exit button)
  • Questionable design of safety equipment (Why use a button instead of a door handle?)
  • Response bias to a likely “false alarm”

Introducing the principle of graceful error recovery to state government

A North Carolina State Representative just accidentally overrode a veto on “fracking” due to being tired and pressing the wrong button during the vote.

Apparently, they aren’t allowed to change their votes if it would alter the overall outcome. So even though she realized it right when she pressed the button, the override stands.

From the article on WRAL:

 Carney characterized her vote as “very accidental.”

“It is late. Here we are rushing to make these kind of decisions this time of night,” she said.

Carney pointed out that she has voted against fracking in the past, and said she spent the day lobbying other Democrats to uphold the veto of Senate Bill 820.

“And then I push the green button,” she said.

Just after the vote, Carney’s voice could be heard on her microphone, saying “Oh my gosh. I pushed green.”

Pilots forget to lower landing gear after cell phone distraction

This is back from May, but it’s worth noting. A news story chock-full of the little events that can add up to disaster!

From the article:

Confused Jetstar pilots forgot to lower the wheels and had to abort a landing in Singapore just 150 metres above the ground, after the captain became distracted by his mobile phone, an investigation has found.

Major points:

  • Pilot forgets to turn off cell phone and receives distracting messages prior to landing.
  • Co-pilot is fatigued.
  •  They do not communicate with each other before taking action.
  •  Another distracting error occurred involving the flap settings on the wings.
  • They do not use the landing checklist.

I was most surprised by that last point – I didn’t know that was optional! Any pilots out there want to weigh in on how frequently checklists are skipped entirely?

 

 

Photo credit slasher-fun @ Flickr

Lack of human factors = more of your tax dollars at “work”

I live in Raleigh, NC. Our area code has always been a little problematic for the nationwide 911 emergency system – it is 919. But at least until now, dialing the 919 for a local call was optional. Looks like we’re finally big enough for ten digit dialing and we can expect to pay the price in our public safety system.  Check out this email from the Director of Emergency Communications, particularly the part about dispatching officers every 7.5 minutes to investigate hang-ups:

I am sure by now that you have seen or heard about some of the impact that the new 10 digit dialing requirement has made upon our 9-1-1 center. Unfortunately, we are almost three weeks downstream from this implementation, and are seeing few signs of improvement.

Neither the 9-1-1 center, the city, or the local telephone carriers are responsible for selecting area codes. They are distributed according to a national plan. “Overlays” are added when a region begins to run out of numbers in their original pool; in this case 9-1-9. Unfortunately, with the similarity between 9-1-9 and 9-1-1, our agency has seen this issue in the past, as some of our citizens have utilized 10 digit dialing for some time. The current impact on our staff – and on law enforcement – is that on our peak days we are dispatching officers to investigate hang up calls once every seven and a half minutes. Of course, this is a daily average, meaning that at peak times the impact is even more severe. Plus, we only dispatch calls that we can’t resolve another way. Many people who misdial don’t realize they have until we answer. Others hang-up, but answer when we call them back. In such cases sending an officer is not required, so the total number of calls we receive in error far exceeds those dispatched.

As Director of Emergency Communications, I am asking for your help. We have identified that a majority of such calls come from either senior citizens or business telephones. In the first case, confusion over the proper procedures seems to be the norm.  After 40 years, folks now have to dial 10 digits just to talk to their neighbor. We’ve had callers tell us they thought they had to now dial 9-1-1 before calling in our area, and others ask if they needed to dial 9-1-9 before they called 9-1-1. If you have an elderly friend, relative, or neighbor, I’d like to personally ask you to take the time to make sure they understand to carefully dial “9-1-9” when required. I believe that with some patience and understanding we can make significant inroads.

With regard to business telephones, the issue is a little more complex, and may in some cases even involve the need to dial “9” to get an outside line, followed by the unnecessary “1” before dialing the area code. Whatever the reason, it really boils down to just taking a few extra seconds to make sure of the numbers you’re dialing. Whether you work at a local business, or own one, can I please also count on you to assure that your co-workers use due care when calling? This is a very serious issue and takes resources away from dealing with actual emergencies.

So, to summarize:

  • There is a lack of understanding when to use 10-digit dialing.
  • Being “careful” is not going to fix this problem.
  • The added traditions for businesses to dial “9” to get out adds to the problem (NC State moved to a dial “7” system, presumably for this reason).
  • Those with a lifetime of 7-digit experience, and presumably the least likely to have numbers pre-programmed into a cell phone, make the most errors.

The issues here are fascinating, yet predictable. I don’t know if there is a perfect answer, since changing the long-term ill-chosen area code would be confusing (although my home town in Alabama has gone through 3 such changes in the last couple of decades – from 205 to 334 to 251!). But it is clear that we are penalized by the similarity of our numbers to a national standard for emergency calls. I applaud the tone of the email, which is not blameful – just desperate for a solution. However, I have great skepticism that advising “due care” in dialing will make any difference at all.

Bad Usability Causes Cranky Babies

I peripherally heard about another Tylenol recall and assumed the recall was prompted by tainted medicine or something.  Anne just sent me a link to the story and it is apparently usability related.  The syringe-based dosing system, called SimpleMeasure, seems to be difficult to use.  Here is what NPR says:

the “SimpleMeasure” dosing system that’s supposed to make it easier to fill a syringe with the right amount of the grapey painkiller and fever-reducer is too complicated for some parents.

Development of the ground proximity warning system for aviation

This article tells the story of inspiration for and creation of a “ground proximity warning” system for pilots, as well as multiple other types of cockpit warnings. Don’t miss the video embedded as a picture in the article! It has the best details!

Some choice excerpts:

About 3.5 miles out from the snow-covered rock face, a red light flashed on the instrument panel and a recorded voice squawked loudly from a speaker.

“Caution — Terrain. Caution — Terrain.”

The pilot ignored it. Just a minute away from hitting the peaks, he held a steady course.

Ten seconds later, the system erupted again, repeating the warning in a more urgent voice.

The pilot still flew on. Snow and rock loomed straight ahead.

Suddenly the loud command became insistent.

“Terrain. Pull up! Pull up! Pull up! Pull up! Pull up!”

Accidents involving controlled flight into terrain still happen, particularly in smaller turboprop aircraft. During the past five years, there have been 50 such accidents, according to Flight Safety Foundation data.

But since the 1990s, the foundation has logged just two in aircraft equipped with Bateman’s enhanced system — one in a British Aerospace BAe-146 cargo plane in Indonesia in 2009; one in an Airbus A321 passenger jet in Pakistan in 2010.

In both cases, the cockpit voice recorder showed the system gave the pilots more than 30 seconds of repeated warnings of the impending collisions, but for some reason the pilots ignored them until too late.

After a Turkish Airlines 737 crashed into the ground heading into Amsterdam in 2009, investigators discovered the pilots were unaware until too late that their air speed was dangerously low on approach. Honeywell added a “low-airspeed” warning to its system, now basic on new 737s.

For the past decade, Bateman has worked on ways of avoiding runway accidents by compiling precise location data on virtually every runway in the world.

Fun with confusing medication names!

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 their proprietary names for similarities. However, Durasal (salicylic acid) is an OTC medication that did not undergo the approval process. That is why the two names exist side-by-side in the pharmacies.

Thus far, the FDA is asking pharmacists to “be vigilant.” I think we know how that usually plays out.

 

*Durezol is eye drops. Durasal is wart remover.