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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
YOU WRONG, YOU DIEAn UX talk about Human Errors, Errant Behaviors and Design
Hoang C. Huynh
ROME 11-12 April 2014
ROME 11-12 April 2014
Hi, I’m Hoang!
I Am Learning German
I Am Easily Bored
I Love Technologies
I Design
Experiences
ROME 11-12 April 2014
Hi, I’m Hoang!
I Am Learning German
I Am Easily Bored
I Love Technologies
I Design
Experiences
HOW PEOPLE WORK
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
USUALLY
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
WE CREATE STORIES
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
The only 'intuitive' interface is the
nipple. After that, it's all learned
Bruce Ediger, Consultant
- @Nipple.es
WE STRUGGLE WITH
INTUITIVENESS
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
AND USABILITY ISSUES
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @CW - Arrow
WE MUST BE
SOMEONE ELSE
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @CW - Arrow
WE MUST BE
SOMETHING ELSE
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
BUT “SOMETIMES”
WE HAVE TO DESIGN
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
FOR PEOPLE WHO
ARE “VOLUNTEERS”
AKA EMPLOYERS
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Landmark - Captain Power and the Soldier of the Future
WE HAVE THE
POWER
TO BRING THEM
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Warner - Constantine
HELL
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Warner - Constantine
OR HEAVEN
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Failing to perform or omitting a task
Performing the task incorrectly
Performing an extra or non-required task
Performing tasks out of sequence
Failing to perform the task within the time limit associated with it
Failing to respond adequately to a contingency
DIFF METRICS
WE HAVE TO DEAL WITH
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Autismhelpers
WE CAN TALK ABOUT
TASK ANALYSIS
!
!
!
!
!
BUT IT WOULD BE
BORING AS HELL
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
#BOOBS
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
#KITTENS
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh- Speaker’s name
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
THE HUMAN ERROR
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
30 AD
Errare humanum est,
!
perseverare autem diabolicum,
et tertia non datur
Lucius Annaeus Seneca, Philosopher
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
1711
To err is human
!
To forgive, divine
Alexander Pope, Poet
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
50-70% of aviation disasters
44,000 – 98,000 deaths / year in US result from med errors
60-85% of shuttle incidents at NASA
92-95% of car crashes
70% of shipping accidents
HUMAN FAILURES
ARE SAID TO ACCOUNT FOR
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
1An inappropriate or undesirable human decision or behavior
that reduces or has the potential for reducing the
effectiveness, dependability or performance of a system
THE DEFINITION
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
1An inappropriate or undesirable human decision or behavior
that reduces or has the potential for reducing the
effectiveness, dependability or performance of a system
THE DEFINITION
2Something has been done that was "not intended by the actor,
not desired by a set of rules or an external observer or that led
the task or system outside its acceptable limits”.
It is a deviation from intention, expectation or desirability.
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
System FAULT
a characteristic
System ERROR
a state
System FAILURE
a behavior
HUMAN ERROR
• Development
• Operational
• Maintenance
HUMAN
SYSTEM
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Warner - Inception
AN ERROR IS NOT
AN ERROR UNTIL
IT IS AN ERROR
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Warner - Inception
WE NEED TO GO
DEEPER
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- Courtesy of Wikipedia
AN ERROR IS NEVER #WRONG BY PER SE
A DISASTER
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Fox - The Simpsons
AN ACCIDENT
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
#NSFW
- @DamnYouAutoCorrect
DUCKING
AUTO CUCUMBER!
A DISTRACTION
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @emilyrebekah
A WIN
The legend of Ivory soap: Back in the late 1800's Proctor and Gamble were
manufacturing their new White Soap with hope to compete in the fine soap market.
!
One day a line worker left the soap mixing machine on while he went to lunch and
when he got back from lunch the soap was extra frothy having incorporated more
air than normal into it. IT FLOATS! (EVEN THO IT’S A MADE UP STORY)
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @NSF DBA
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
The Three Mile Island accident was a partial nuclear meltdown
which occurred in one of the two Three Mile Island nuclear
reactors in Dauphin County, Pennsylvania, US, on March 28, 1979.
!
It was the worst accident in U.S. nuclear power plant history.
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- Courtesy of Wikipedia
The crash occurred at
Fairchild Air Force Base,
US, on 24 June 1994, when
the pilot of a USAF Boeing
B-52 Stratofortress, Arthur
Holland, flew the aircraft
beyond its operational
limits and lost control.
“Requesting permission for flyby!”
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Wikipedia / @Warner - Lord of the Rings
THE GIMLI GLIDER
This accident was caused by a human error in 1983. Fuel loading was miscalculated due to a
misunderstanding of the recently adopted metric system which replaced the imperial system.
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Gizmodo / Shutterstock/Ilja Mašík
In the 2011, an All Nippon Airways passenger plane carrying 117 due to a human error continued to roll
until it reached 131.7 degrees to the left, leaving it almost belly-up.
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Gizmodo
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
NEARLY DEATH EXPERIENCE DOOR OPENING
- @Gizmodo
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
REGULATIONS
ORGANIZATIONS
TECHNOLOGY
INDIVIDUALS
THE SHARP END OF FAILURE
GROUPS
How comes that we blame
individuals first?
Blaming individuals is emotionally more satisfying than targeting institutions.
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
1969
To err is human
!
but to really foul things up
you need a computer.
Paul Ehrlich , Scientist
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
No scheme particularly useful
Partly because human error is complex
Schemes do not capture that complexity
Often the full facts are not available
Essentially,
all models are wrong,
but some are useful
George E. P. Box, Statistician
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Discrete Action Classification
Errors of omission (not doing the required task)
Forgetting to do it
Ignoring to do it deliberately
!
Errors of commission (doing the wrong task)
!
Slips in which the operator has the correct intention, but carries out the
wrong execution
!
•Selection
•Sequence or wrong order of execution
•Timing: too fast/ too slow / too late
•Quantity: too much / not enough
Swain & Guttman 1983
THERPTechnique for Human
Error Rate Prediction
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Skill based
controlled by sub-conscious behavior and stored patterns of behavior
errors usually errors of execution
!
Rule based
applies to familiar situations - stored rules are applied
errors involve recognizing the salient features of the situation
!
Knowledge based
occur in unique & unfamiliar situations
errors result from inadequate analysis or decision making
Performance / S.R.K Classification
Rasmussen 1982
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Skill based
- @Huffpost
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Rule based
WHERE ARE THE TOILETTES?
On the right, over there
:| No…#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Marvel - The Avengers
Knowledge based (negative)
CAN YOU RUN A FLIGHT
DIAGNOSTIC ON THE MARK IV?
#MAYBEWRONG
Yes… but…
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Knowledge based (positive)
“ALL THE JAEGER ARE DIGITAL”
#WRONG! Gipsy’s Analog, Nuclear!
- @Warner Bros - Pacific Rim
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
"The division occurs at
the level of the intention:
!
A Person establishes an
intention to act.
!
If the intention is not
appropriate, this is a
mistake. If the action is
not what was intended,
this is a slip."
GEMSGeneric Error Modeling System
Reason 1990
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Are an “execution failure”, where the operator’s intentions are
correct but actions are not carried out properly
Slips, which occur in skills based performance
Also are an “execution failure”, but this time where an operator
forgets to do something, loses their place in a task, etc.
Lapses, which also occur in skills based performance
These are “planning failures”, where an inappropriate set of actions
is carried out
Mistakes, which occur in rule and knowledge based performance
CLASSIFICATION
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Skills Based Errors Rule Based Errors Knowledge Based
Errors
Main Error type Slips & Lapses RB mistakes KB mistakes
Activity type Routine actions Problems solving activities
Attention Often elsewhere Directed at problem related issues
Control mode Mainly automatic More conscious
Predictability Largely
predictable
variable
Frequency Common Uncommon
Opportunity Very high Very low
Detection Usually easy Difficult and often through intervention
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Skills Based Errors Rule Based Errors Knowledge Based
Errors
Main Error type Slips & Lapses RB mistakes KB mistakes
Activity type Routine actions Problems solving activities
Attention Often elsewhere Directed at problem related issues
Control mode Mainly automatic More conscious
Predictability Largely
predictable
variable
Frequency Common Uncommon
Opportunity Very high Very low
Detection Usually easy Difficult and often through intervention
Approximate data (Reason, 1990)
61% 28% 11%
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Capture Slip: automatic activation of a well-learned routine that overrides the
current intended activity .
Omission Slip: Omissions due to interruption
Loss of Activation Slip: Ignoring the activation trigger for the intention
Description Slip: incomplete or ambiguous specification of intention that is similar
to a familiar intention.
Associative Activation Slip: activation of similar but incorrect schemas.
Perceptual Confusion Slip: activation of the correct schema with the wrong item
Reverse Schema Slip: reverse action schema overwrites forward action schema.
Cross-talk Slip: action components are exchanged between two or more
sequential or concurrent actions.
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Capture Slip
Omission Slip
Loss of Activation Slip
Description Slip
Associative Activation Slip
Reverse Schema Slip
Cross-talk Slip
Perceptual Confusion Slip
• Driving to the office on Saturday instead of home
• Forget to send and interrupted email
• Walking into a room without remembering the reason
• Slide the credit card into the hotel door instead of
the key card
• Tap a clearly non touchable touchscreen
• Washing hands with the hair gel instead of the soap
• Open the purse and putting it away before paying
• Start writing a document in mother tongue and
completing it in a foreign language
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Capture Slip
Omission Slip
Loss of Activation Slip
Description Slip
Associative Activation Slip
Reverse Schema Slip
Cross-talk Slip
Perceptual Confusion Slip
• Driving to the office on Saturday instead of home
• Forget to send and interrupted email
• Walking into a room without remembering the reason
• Slide the credit card into the hotel door instead of
the key card
• Tap a non touchable touchscreen
• Washing hands with the hair gel instead of the soap
• Open the purse and putting it away before paying
• Start writing a document in mother tongue and
completing it in a foreign language
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Capture Slip
Omission Slip
Loss of Activation Slip
Description Slip
Associative Activation Slip
Reverse Schema Slip
Cross-talk Slip
Perceptual Confusion Slip
• Driving to the office on Saturday instead of home
• Forget to send and interrupted email
• Walking into a room without remembering the reason
• Slide the credit card into the hotel door instead of
the key card
• Tap a non touchable touchscreen
• Washing hands with the hair gel instead of the soap
• Open the purse and putting it away before paying
• Start writing a document in mother tongue and
completing it in a foreign language
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Ansa
An old lady went
under surgery and got
a prosthesis in the
wrong leg… then she
got one in the right
one.. then she died…
!
A l l e g e d l y , t h e y
switched table side
before the surgery,
they were in hurry
and they forgot to
turn the patient as
well…
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Our behavior is
regulated by the
activation and
deactivation of
schemas
EXECUTE
ORDER 66
- @Disney - Star Wars
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @PlankingPhotos
Any schema comes
with an activation
trigger, a primary goal
and an indefinite
number of subgoals
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @PlankingPhotos
Any schema comes
with an activation
trigger, a primary goal
and an indefinite
number of subgoals
WHAT HAPPENS WHEN THE PRIMARY GOAL IS
TRIGGERED BEFORE THE COMPLETION OF THE
SUB GOALS ?
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @PlankingPhotos
YOU FORGET THE
ORIGINALS IN THE
MACHINE
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @PlankingPhotos
YOU FORGET YOUR
CREDIT CARD IN THE
READER
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @PlankingPhotos
YOU FORGET YOUR
CHANGE IN THE
VENDING MACHINE
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
John Davidson holds the
unfortunate distinction of
being the first person in the
worldwide Millionaire franchise
to win nothing at all. He
appeared as a contestant on
J a n u a r y 1 0 , 1 9 9 9 , b u t
answered his £1,000 question
incorrectly.
WHEN EVERYTHING COMES TOGETHER YOU
WILL EPICALLY #FAIL
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
EPIC FAIL
TRIGGER
DISASTER / ACCIDENT
EVENT
DEFENSES
LATENT /ACTIVE
FAILURES
MISSED OPPORTUNITIES
ABSENT DEFENSES
UNSAFE ACTS
REASON’s SWISS CHEESE MODEL
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
#SOWRONGSPEAKING ABOUT DISASTERS
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
THE ICEBERG
COLLISION
SHIPWRECK
NO AIDS
NO RESCUE
LACK OF BOATS
HIGH SEA
LOW VISIBILITY
TITANIC
#SOWRONGFAULT TREE ANALYSIS
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Fox - The Simpsons
DESIGN
FOR ERRORSand Design for Failure or Design for Recovery
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Human error is in OUR NATURE
It might happen everyone, at any time, in any context.
!
IT IS INEVITABLE.
!
Some errors are PREVENTABLE
through better system design of
equipment, procedures and work
environment.
(BTW RECOVERY AND RESILIENCE are
MUCH BETTER than prevention)
!
Human error might not be an
accident cause in itself…it might
be caused by MULTIPLE FACTORS
#WRONG
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Avoidance and Prevention
Design the system so that certain classes of human error are eliminated, by
implementing procedures, training, safety awareness and UI design where
people aren’t distracted or overwhelmed, but aren’t bored either
!
Detection
Make it easier for the operator and others to spot errors by designing systems
and work environments where people are able to understand what is
happening and the consequences of an action
!
Tolerance
Ensure that individual errors are unlikely to lead to system failure and minimise
potential for deliberate violations by making sure rules are well designed and
well understood
!
Recover
Ensure Undo capability, confirmation
DESIGN YOUR SYSTEM
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
DISC LOCK REMINDER
STRATEGIES
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @FOX - Futurama
AUTOMATE
( YES WE ARE DOOMED )
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @unsplash
FORCING FUNCTIONS
INTERLOCKS LOCKINS LOCKOUTS
Force certain sequences of
events, e.g. the Credit Card
recollection on ATMs is
forced before the withdraw
of money.
These stop you for
carrying out a certain
action in a particular
context, e.g. you
cannot exit a editing
s o f t w a r e w i t h o u t
validating the save
prompt
S t o p y o u f o r d o i n g
something. e,g, the stairs
to the basement of a tall
b u i l d i n g a r e u s u a l l y
differently designed or
have a gate to stop people
continuing to the basement
when evacuating.
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Unsplash
Distractions
Incomplete or incorrect data
Boredom
Inadequate resources
Cognitive overload
Stress
Illness
Time pressure
TAKE IN CONSIDERATION
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
•Pursue second stories beneath the surface to discover multiple contributors.
•Escape the hindsight bias
•Understand work as performed at the sharp end of the system
•Search for systemic vulnerabilities
•Study how practice creates safety
•Search for underlying patterns
•Examine how changes create new vulnerabilities
•Used new technology to support and enhanced human expertise
•Tame complexity through new forms of feedback
Be aware of possible influencing situational factors.
Be aware of the hindsight bias of the retrospective analyst.
ADD THESE TO YOUR UX CHECKLIST
Woods & Cook (2002)
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
PREVENT FEEDBACK WTF?
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
TONIGHT WE DINE
IN HELL
- @Warner - 300
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
TONIGHT WE DINE
IN HELL
BUT TOMORROW, I’M
THINKING MCDONALDS- @Warner - 300
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
General
That button launches all of our
nuclear missiles!
President Hathaway
Well which button gets me a latte?
Advisor
That would be the other one, sir.
President Hathaway
What idiot designed this thing?
President Hathaway
You did, sir.
- @Dreamworks - Monsters VS Aliens
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
NEARLY DEATH EXPERIENCE DOOR OPENING
- @Gizmodo
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Aetheros
Twitter: @aetheros
Linkedin: in/hchuynh
Web: huynh.cc/blog
Slides will be available also
on slideshare/aetheros
THANK YOU
ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
Sources
http://www.slideshare.net/rezazarei125/human-error
http://www.slideshare.net/johnrooksby/cs5032-l5-human-error-1
http://www.slideshare.net/johnrooksby/cs5032-lecture-2-failure-11609657
http://www.slideshare.net/dominicfurniss/human-error-lecture
Reason, J. (1990). Human Error. Cambridge University Press.
Norman, D.A. (1981). Categorization of action slips. Psychological Review, 88, 1-15.
http://en.wikipedia.org/wiki/Human_error
http://wikiofscience.wikidot.com/quasiscience:error
Francesco Di Nocera, Ergonomia cognitiva, Carocci, Roma, 2011
Donald Norman, La caffettiera del masochista, Giunti, Milano, 1990
Donald Norman, Emotional design, Apogeo, Milano, 2004
http://www.slideshare.net/Yehoshua7/schneider-electric-nuclear-navy-and-reducing-human-error

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You WRONG, You DIE #Codemotion 2014

  • 1. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh YOU WRONG, YOU DIEAn UX talk about Human Errors, Errant Behaviors and Design Hoang C. Huynh ROME 11-12 April 2014
  • 2. ROME 11-12 April 2014 Hi, I’m Hoang! I Am Learning German I Am Easily Bored I Love Technologies I Design Experiences
  • 3. ROME 11-12 April 2014 Hi, I’m Hoang! I Am Learning German I Am Easily Bored I Love Technologies I Design Experiences HOW PEOPLE WORK
  • 4. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh USUALLY
  • 5. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh WE CREATE STORIES
  • 6. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh The only 'intuitive' interface is the nipple. After that, it's all learned Bruce Ediger, Consultant - @Nipple.es WE STRUGGLE WITH INTUITIVENESS
  • 7. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh AND USABILITY ISSUES
  • 8. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @CW - Arrow WE MUST BE SOMEONE ELSE
  • 9. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @CW - Arrow WE MUST BE SOMETHING ELSE
  • 10. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh BUT “SOMETIMES” WE HAVE TO DESIGN
  • 11. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh FOR PEOPLE WHO ARE “VOLUNTEERS” AKA EMPLOYERS
  • 12. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Landmark - Captain Power and the Soldier of the Future WE HAVE THE POWER TO BRING THEM
  • 13. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Warner - Constantine HELL
  • 14. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Warner - Constantine OR HEAVEN
  • 15. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Failing to perform or omitting a task Performing the task incorrectly Performing an extra or non-required task Performing tasks out of sequence Failing to perform the task within the time limit associated with it Failing to respond adequately to a contingency DIFF METRICS WE HAVE TO DEAL WITH
  • 16. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Autismhelpers WE CAN TALK ABOUT TASK ANALYSIS ! ! ! ! ! BUT IT WOULD BE BORING AS HELL
  • 17. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh #BOOBS
  • 18. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh #KITTENS
  • 19. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh- Speaker’s name
  • 20. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh THE HUMAN ERROR
  • 21. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh 30 AD Errare humanum est, ! perseverare autem diabolicum, et tertia non datur Lucius Annaeus Seneca, Philosopher
  • 22. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh 1711 To err is human ! To forgive, divine Alexander Pope, Poet
  • 23. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh 50-70% of aviation disasters 44,000 – 98,000 deaths / year in US result from med errors 60-85% of shuttle incidents at NASA 92-95% of car crashes 70% of shipping accidents HUMAN FAILURES ARE SAID TO ACCOUNT FOR
  • 24. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh 1An inappropriate or undesirable human decision or behavior that reduces or has the potential for reducing the effectiveness, dependability or performance of a system THE DEFINITION
  • 25. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh 1An inappropriate or undesirable human decision or behavior that reduces or has the potential for reducing the effectiveness, dependability or performance of a system THE DEFINITION 2Something has been done that was "not intended by the actor, not desired by a set of rules or an external observer or that led the task or system outside its acceptable limits”. It is a deviation from intention, expectation or desirability.
  • 26. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh System FAULT a characteristic System ERROR a state System FAILURE a behavior HUMAN ERROR • Development • Operational • Maintenance HUMAN SYSTEM
  • 27. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Warner - Inception AN ERROR IS NOT AN ERROR UNTIL IT IS AN ERROR
  • 28. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Warner - Inception WE NEED TO GO DEEPER
  • 29. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - Courtesy of Wikipedia AN ERROR IS NEVER #WRONG BY PER SE A DISASTER
  • 30. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Fox - The Simpsons AN ACCIDENT #WRONG
  • 31. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh #NSFW - @DamnYouAutoCorrect DUCKING AUTO CUCUMBER! A DISTRACTION #WRONG
  • 32. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @emilyrebekah A WIN The legend of Ivory soap: Back in the late 1800's Proctor and Gamble were manufacturing their new White Soap with hope to compete in the fine soap market. ! One day a line worker left the soap mixing machine on while he went to lunch and when he got back from lunch the soap was extra frothy having incorporated more air than normal into it. IT FLOATS! (EVEN THO IT’S A MADE UP STORY)
  • 33. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @NSF DBA
  • 34. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh The Three Mile Island accident was a partial nuclear meltdown which occurred in one of the two Three Mile Island nuclear reactors in Dauphin County, Pennsylvania, US, on March 28, 1979. ! It was the worst accident in U.S. nuclear power plant history. #WRONG
  • 35. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - Courtesy of Wikipedia The crash occurred at Fairchild Air Force Base, US, on 24 June 1994, when the pilot of a USAF Boeing B-52 Stratofortress, Arthur Holland, flew the aircraft beyond its operational limits and lost control. “Requesting permission for flyby!” #WRONG
  • 36. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Wikipedia / @Warner - Lord of the Rings THE GIMLI GLIDER This accident was caused by a human error in 1983. Fuel loading was miscalculated due to a misunderstanding of the recently adopted metric system which replaced the imperial system. #WRONG
  • 37. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Gizmodo / Shutterstock/Ilja Mašík In the 2011, an All Nippon Airways passenger plane carrying 117 due to a human error continued to roll until it reached 131.7 degrees to the left, leaving it almost belly-up. #WRONG
  • 38. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Gizmodo
  • 39. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh NEARLY DEATH EXPERIENCE DOOR OPENING - @Gizmodo
  • 40. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh REGULATIONS ORGANIZATIONS TECHNOLOGY INDIVIDUALS THE SHARP END OF FAILURE GROUPS How comes that we blame individuals first? Blaming individuals is emotionally more satisfying than targeting institutions.
  • 41. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh 1969 To err is human ! but to really foul things up you need a computer. Paul Ehrlich , Scientist
  • 42. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh No scheme particularly useful Partly because human error is complex Schemes do not capture that complexity Often the full facts are not available Essentially, all models are wrong, but some are useful George E. P. Box, Statistician
  • 43. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Discrete Action Classification Errors of omission (not doing the required task) Forgetting to do it Ignoring to do it deliberately ! Errors of commission (doing the wrong task) ! Slips in which the operator has the correct intention, but carries out the wrong execution ! •Selection •Sequence or wrong order of execution •Timing: too fast/ too slow / too late •Quantity: too much / not enough Swain & Guttman 1983 THERPTechnique for Human Error Rate Prediction
  • 44. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Skill based controlled by sub-conscious behavior and stored patterns of behavior errors usually errors of execution ! Rule based applies to familiar situations - stored rules are applied errors involve recognizing the salient features of the situation ! Knowledge based occur in unique & unfamiliar situations errors result from inadequate analysis or decision making Performance / S.R.K Classification Rasmussen 1982
  • 45. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Skill based - @Huffpost #WRONG
  • 46. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Rule based WHERE ARE THE TOILETTES? On the right, over there :| No…#WRONG
  • 47. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Marvel - The Avengers Knowledge based (negative) CAN YOU RUN A FLIGHT DIAGNOSTIC ON THE MARK IV? #MAYBEWRONG Yes… but…
  • 48. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Knowledge based (positive) “ALL THE JAEGER ARE DIGITAL” #WRONG! Gipsy’s Analog, Nuclear! - @Warner Bros - Pacific Rim
  • 49. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh "The division occurs at the level of the intention: ! A Person establishes an intention to act. ! If the intention is not appropriate, this is a mistake. If the action is not what was intended, this is a slip." GEMSGeneric Error Modeling System Reason 1990
  • 50. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Are an “execution failure”, where the operator’s intentions are correct but actions are not carried out properly Slips, which occur in skills based performance Also are an “execution failure”, but this time where an operator forgets to do something, loses their place in a task, etc. Lapses, which also occur in skills based performance These are “planning failures”, where an inappropriate set of actions is carried out Mistakes, which occur in rule and knowledge based performance CLASSIFICATION
  • 51. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Skills Based Errors Rule Based Errors Knowledge Based Errors Main Error type Slips & Lapses RB mistakes KB mistakes Activity type Routine actions Problems solving activities Attention Often elsewhere Directed at problem related issues Control mode Mainly automatic More conscious Predictability Largely predictable variable Frequency Common Uncommon Opportunity Very high Very low Detection Usually easy Difficult and often through intervention
  • 52. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Skills Based Errors Rule Based Errors Knowledge Based Errors Main Error type Slips & Lapses RB mistakes KB mistakes Activity type Routine actions Problems solving activities Attention Often elsewhere Directed at problem related issues Control mode Mainly automatic More conscious Predictability Largely predictable variable Frequency Common Uncommon Opportunity Very high Very low Detection Usually easy Difficult and often through intervention Approximate data (Reason, 1990) 61% 28% 11%
  • 53. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Capture Slip: automatic activation of a well-learned routine that overrides the current intended activity . Omission Slip: Omissions due to interruption Loss of Activation Slip: Ignoring the activation trigger for the intention Description Slip: incomplete or ambiguous specification of intention that is similar to a familiar intention. Associative Activation Slip: activation of similar but incorrect schemas. Perceptual Confusion Slip: activation of the correct schema with the wrong item Reverse Schema Slip: reverse action schema overwrites forward action schema. Cross-talk Slip: action components are exchanged between two or more sequential or concurrent actions.
  • 54. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Capture Slip Omission Slip Loss of Activation Slip Description Slip Associative Activation Slip Reverse Schema Slip Cross-talk Slip Perceptual Confusion Slip • Driving to the office on Saturday instead of home • Forget to send and interrupted email • Walking into a room without remembering the reason • Slide the credit card into the hotel door instead of the key card • Tap a clearly non touchable touchscreen • Washing hands with the hair gel instead of the soap • Open the purse and putting it away before paying • Start writing a document in mother tongue and completing it in a foreign language
  • 55. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Capture Slip Omission Slip Loss of Activation Slip Description Slip Associative Activation Slip Reverse Schema Slip Cross-talk Slip Perceptual Confusion Slip • Driving to the office on Saturday instead of home • Forget to send and interrupted email • Walking into a room without remembering the reason • Slide the credit card into the hotel door instead of the key card • Tap a non touchable touchscreen • Washing hands with the hair gel instead of the soap • Open the purse and putting it away before paying • Start writing a document in mother tongue and completing it in a foreign language
  • 56. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Capture Slip Omission Slip Loss of Activation Slip Description Slip Associative Activation Slip Reverse Schema Slip Cross-talk Slip Perceptual Confusion Slip • Driving to the office on Saturday instead of home • Forget to send and interrupted email • Walking into a room without remembering the reason • Slide the credit card into the hotel door instead of the key card • Tap a non touchable touchscreen • Washing hands with the hair gel instead of the soap • Open the purse and putting it away before paying • Start writing a document in mother tongue and completing it in a foreign language
  • 57. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Ansa An old lady went under surgery and got a prosthesis in the wrong leg… then she got one in the right one.. then she died… ! A l l e g e d l y , t h e y switched table side before the surgery, they were in hurry and they forgot to turn the patient as well…
  • 58. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Our behavior is regulated by the activation and deactivation of schemas EXECUTE ORDER 66 - @Disney - Star Wars
  • 59. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @PlankingPhotos Any schema comes with an activation trigger, a primary goal and an indefinite number of subgoals
  • 60. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @PlankingPhotos Any schema comes with an activation trigger, a primary goal and an indefinite number of subgoals WHAT HAPPENS WHEN THE PRIMARY GOAL IS TRIGGERED BEFORE THE COMPLETION OF THE SUB GOALS ?
  • 61. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @PlankingPhotos YOU FORGET THE ORIGINALS IN THE MACHINE #WRONG
  • 62. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @PlankingPhotos YOU FORGET YOUR CREDIT CARD IN THE READER #WRONG
  • 63. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @PlankingPhotos YOU FORGET YOUR CHANGE IN THE VENDING MACHINE #WRONG
  • 64. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh John Davidson holds the unfortunate distinction of being the first person in the worldwide Millionaire franchise to win nothing at all. He appeared as a contestant on J a n u a r y 1 0 , 1 9 9 9 , b u t answered his £1,000 question incorrectly. WHEN EVERYTHING COMES TOGETHER YOU WILL EPICALLY #FAIL
  • 65. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh EPIC FAIL TRIGGER DISASTER / ACCIDENT EVENT DEFENSES LATENT /ACTIVE FAILURES MISSED OPPORTUNITIES ABSENT DEFENSES UNSAFE ACTS REASON’s SWISS CHEESE MODEL
  • 66. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh #SOWRONGSPEAKING ABOUT DISASTERS
  • 67. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh THE ICEBERG COLLISION SHIPWRECK NO AIDS NO RESCUE LACK OF BOATS HIGH SEA LOW VISIBILITY TITANIC #SOWRONGFAULT TREE ANALYSIS
  • 68. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Fox - The Simpsons DESIGN FOR ERRORSand Design for Failure or Design for Recovery
  • 69. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Human error is in OUR NATURE It might happen everyone, at any time, in any context. ! IT IS INEVITABLE. ! Some errors are PREVENTABLE through better system design of equipment, procedures and work environment. (BTW RECOVERY AND RESILIENCE are MUCH BETTER than prevention) ! Human error might not be an accident cause in itself…it might be caused by MULTIPLE FACTORS #WRONG
  • 70. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Avoidance and Prevention Design the system so that certain classes of human error are eliminated, by implementing procedures, training, safety awareness and UI design where people aren’t distracted or overwhelmed, but aren’t bored either ! Detection Make it easier for the operator and others to spot errors by designing systems and work environments where people are able to understand what is happening and the consequences of an action ! Tolerance Ensure that individual errors are unlikely to lead to system failure and minimise potential for deliberate violations by making sure rules are well designed and well understood ! Recover Ensure Undo capability, confirmation DESIGN YOUR SYSTEM
  • 71. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh DISC LOCK REMINDER STRATEGIES
  • 72. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @FOX - Futurama AUTOMATE ( YES WE ARE DOOMED )
  • 73. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @unsplash FORCING FUNCTIONS INTERLOCKS LOCKINS LOCKOUTS Force certain sequences of events, e.g. the Credit Card recollection on ATMs is forced before the withdraw of money. These stop you for carrying out a certain action in a particular context, e.g. you cannot exit a editing s o f t w a r e w i t h o u t validating the save prompt S t o p y o u f o r d o i n g something. e,g, the stairs to the basement of a tall b u i l d i n g a r e u s u a l l y differently designed or have a gate to stop people continuing to the basement when evacuating.
  • 74. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Unsplash Distractions Incomplete or incorrect data Boredom Inadequate resources Cognitive overload Stress Illness Time pressure TAKE IN CONSIDERATION
  • 75. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh •Pursue second stories beneath the surface to discover multiple contributors. •Escape the hindsight bias •Understand work as performed at the sharp end of the system •Search for systemic vulnerabilities •Study how practice creates safety •Search for underlying patterns •Examine how changes create new vulnerabilities •Used new technology to support and enhanced human expertise •Tame complexity through new forms of feedback Be aware of possible influencing situational factors. Be aware of the hindsight bias of the retrospective analyst. ADD THESE TO YOUR UX CHECKLIST Woods & Cook (2002)
  • 76. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh PREVENT FEEDBACK WTF?
  • 77. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh TONIGHT WE DINE IN HELL - @Warner - 300
  • 78. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh TONIGHT WE DINE IN HELL BUT TOMORROW, I’M THINKING MCDONALDS- @Warner - 300
  • 79. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh General That button launches all of our nuclear missiles! President Hathaway Well which button gets me a latte? Advisor That would be the other one, sir. President Hathaway What idiot designed this thing? President Hathaway You did, sir. - @Dreamworks - Monsters VS Aliens
  • 80. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh NEARLY DEATH EXPERIENCE DOOR OPENING - @Gizmodo
  • 81. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh - @Aetheros Twitter: @aetheros Linkedin: in/hchuynh Web: huynh.cc/blog Slides will be available also on slideshare/aetheros THANK YOU
  • 82. ROME 11-12 April 2014 You Wrong, You Die - Hoang C. Huynh Sources http://www.slideshare.net/rezazarei125/human-error http://www.slideshare.net/johnrooksby/cs5032-l5-human-error-1 http://www.slideshare.net/johnrooksby/cs5032-lecture-2-failure-11609657 http://www.slideshare.net/dominicfurniss/human-error-lecture Reason, J. (1990). Human Error. Cambridge University Press. Norman, D.A. (1981). Categorization of action slips. Psychological Review, 88, 1-15. http://en.wikipedia.org/wiki/Human_error http://wikiofscience.wikidot.com/quasiscience:error Francesco Di Nocera, Ergonomia cognitiva, Carocci, Roma, 2011 Donald Norman, La caffettiera del masochista, Giunti, Milano, 1990 Donald Norman, Emotional design, Apogeo, Milano, 2004 http://www.slideshare.net/Yehoshua7/schneider-electric-nuclear-navy-and-reducing-human-error