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Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error

1 rating: 3.0
A book by S. M. Casey

...extremely readable and fascinating... recommended to anyone, particularly those interested in human factors research or design. Marine Technology --Marine Technology    Shows how basic paradigms, assumptions, and minor oversights … see full wiki

Tags: Book
Author: S. M. Casey
Genre: Professional & Technical, Science
Publisher: Aegean
1 review about Set Phasers on Stun: And Other True Tales...

Bad design can kill you

  • May 24, 2010
According to Russell Baker: "The goal of all inanimate objects is to resist man and ultimately to defeat him".

This is certainly true in my world - not a day goes by without some episode that confirms the notion that inanimate objects are conspiring against me. I'll admit - sometimes the problem is my own stunning lack of physical coordination (my clumsiness knows no bounds). But I do feel oppressed by the tyranny of bad design - the completely non-intuitive nature of the new microwave, the constantly metastasizing collection of remotes, all those unexplored capabilities of my cell phone, the appalling hideosity of Windows XP. This makes me a sucker for books like this one, where the fundamental emphasis is on the contribution of poor design to bad results.

The book is a compilation of real-life histories, each chosen to illustrate Steven Casey's basic message. This is straightforward; attributing disastrous outcomes to "human error" is often not the complete story - in many cases the real problem turns out to be poor design decisions that make no allowance for the way that people actually interact with technology. So when a software glitch in the Therac-25 machine used to administer radiation therapy to the misfortunate patient in the title vignette causes the machine to deliver a dose of 25,000 volts in a proton beam powered by 25 million electron volts with the protective shield inactivated, the radiotherapy technician receives no signal that anything has gone wrong and proceeds to repeat the mistake twice more, thereby sealing the patient's eventual death warrant.

In the collection of twenty anecdotes that make up this book, almost nobody comes to a good end. Russian cosmonauts perish when the safety valve in their re-entry module proves inoperable under actual emergency conditions, workers at an Idaho nuclear power plant inadvertently dislodge a rod during routine maintenance and trigger a meltdown, pilots crash planeloads of passengers due to (avoidable) confusion based on ambiguous or false information received from the instrument panel, and in Bhopal over 2500 people die as a toxic cloud of methyl isocyanate descends over the sleeping city. In other news, a four-month old baby dies immediately in the ICU when her nurse inadvertently connects an EKG lead to one from the IV pump; an 8-year old boy narrowly escapes invasive, potentially disfiguring, surgery when an alert radiologist figures out that the apparent lesion detected by his senior colleague is actually an artifact caused by leakage of X-ray contrast dye onto the film; at the San Francisco watering hole The Peppermint Twist several customers lose their esophagi after being served a delicious glass of the cleaning liquid Eco-Klene in lieu of the featured happy hour special, the watermelon shot.

Not all of the incidents in the book are fatal. When the captain of the oil tanker Torrey Canyon collides head-on with the Scilly Isles, the only victims of the ensuing 31-million gallon oil spill are the flora and fauna along the beaches of the south of England and the north of France. The chaos that ensued in March 1992 when a hapless Salomon Brothers trader engaged in programmed trading filed an order to sell 11 million shares of stock (instead of 11 million dollars worth) was limited because he did so just a few minutes before the closing bell. However, in September 1923, when Commodore Donald Hunter ordered radio operators further down the food chain to "correct" their position readings based on nothing more than the certainty that his calculations and gut instinct were more reliable than their "new-fangled technology", things did not end well. Seven destroyers and 23 sailors had their lives cut short as a result.

Casey's recurring point is that each disaster was not just a result of human error, but of human error caused by poorly designed technology. Most of the design errors fall into depressingly predictable categories: unintelligible or counterintuitive instrumentation, systems without the necessary communication channels, failsafe mechanisms that proved not to be, alarms that failed to trigger or that triggered so often they were ignored in a genuine emergency, a failure to recognize how behavior in a hierarchical organization can shut down crucial communication links.

The examples Casey provides are all reasonably clear illustrations of his message. And yet I was somewhat disappointed by the book. His writing style is clear, but so pedestrian that the word "plodding" comes to mind. Given the richness of his material, one can't help wondering how much more vividly these stories might have been presented in the hands of a better writer. (Somehow it came as no surprise to learn that the book's title, which is probably the best thing about it, is attributable to Ray Cox, the patient who died as a result of the accident in the first vignette, and not to the author). Another disappointment is the author's failure (which he acknowledges to be deliberate) to provide any analysis of each disaster; though he does present the facts of each case clearly, a little commentary would have been welcome.

"Set Phasers on Stun" covers similar ground to Donald A. Norman's classic The Design of Everyday Things and Simon LeVay's When Science Goes Wrong. It is a distinct improvement on the latter, but fails to reach the incisive clarity of the former. It earns four stars, but lacks the spark that would bump its rating to five.

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