You WRONG, You DIE #Codemotion 2014

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

Hi, I’m Hoang!

I Am Learning GermanI Am Easily BoredI Love Technologies

I Design Experiences

Hi, I’m Hoang!

I Am Learning GermanI Am Easily BoredI Love Technologies

I Design ExperiencesHOW PEOPLE WORK

You Wrong, You Die

- Hoang C. Huynh

USUALLY

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WE CREATE STORIES

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The only 'intuitive' interface is the nipple. After that, it's all learned

Bruce Ediger, Consultant

- @Nipple.es

WE STRUGGLE WITH INTUITIVENESS

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AND USABILITY ISSUES

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- @CW - Arrow

WE MUST BE SOMEONE ELSE

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- @CW - Arrow

WE MUST BE SOMETHING ELSE

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BUT “SOMETIMES”WE HAVE TO DESIGN

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FOR PEOPLE WHO ARE “VOLUNTEERS”

AKA EMPLOYERS

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- @Landmark - Captain Power and the Soldier of the Future

WE HAVE THE POWERTO BRING THEM

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- @Warner - Constantine

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- @Warner - Constantine

OR HEAVEN

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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 METRICSWE HAVE TO DEAL WITH

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- @Autismhelpers

WE CAN TALK ABOUT

TASK ANALYSIS !

BUT IT WOULD BE

BORING AS HELL

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- Hoang C. Huynh

#BOOBS

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#KITTENS

You Wrong, You Die

- Hoang C. Huynh- Speaker’s name

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THE HUMAN ERROR

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30 ADErrare humanum est, !

perseverare autem diabolicum, et tertia non datur

Lucius Annaeus Seneca, Philosopher

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1711To err is human !

To forgive, divine

Alexander Pope, Poet

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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

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

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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.

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

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- @Warner - Inception

AN ERROR IS NOT AN ERROR UNTIL

IT IS AN ERROR

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- @Warner - Inception

WE NEED TO GO

DEEPER

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- Hoang C. Huynh

- Courtesy of Wikipedia

AN ERROR IS NEVER #WRONG BY PER SEA DISASTER

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- @Fox - The Simpsons

AN ACCIDENT#WRONG

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#NSFW- @DamnYouAutoCorrect

DUCKING AUTO CUCUMBER!

A DISTRACTION#WRONG

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- @emilyrebekah

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)

You Wrong, You Die

- Hoang C. Huynh

- @NSF DBA

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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

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- 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

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

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

You Wrong, You Die

- Hoang C. Huynh

- @Gizmodo

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NEARLY DEATH EXPERIENCE DOOR OPENING

- @Gizmodo

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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.

You Wrong, You Die

- Hoang C. Huynh

1969To err is human !

but to really foul things up you need a computer.

Paul Ehrlich , Scientist

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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

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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

THERP Technique for Human

Error Rate Prediction

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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

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Skill based

- @Huffpost #WRONG

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Rule based

WHERE ARE THE TOILETTES? On the right, over there

:| No…#WRONG

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- @Marvel - The Avengers

Knowledge based (negative)

CAN YOU RUN A FLIGHT DIAGNOSTIC ON THE MARK IV?

#MAYBEWRONG

Yes… but…

You Wrong, You Die

- Hoang C. Huynh

Knowledge based (positive)

“ALL THE JAEGER ARE DIGITAL”#WRONG! Gipsy’s Analog, Nuclear!

- @Warner Bros - Pacific Rim

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."

GEMS Generic Error Modeling System

Reason 1990

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

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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

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%

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.

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

You Wrong, You Die

- Hoang C. Huynh

Capture Slip

Omission Slip

Description Slip

Reverse Schema Slip

Cross-talk Slip

• Tap a non touchable touchscreen

You Wrong, You Die

- Hoang C. Huynh

Capture Slip

Omission Slip

Description Slip

Reverse Schema Slip

Cross-talk Slip

• Tap a non touchable touchscreen

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…

You Wrong, You Die

- Hoang C. Huynh

Our behavior is regulated by the

activation and deactivation of

schemas

EXECUTE ORDER 66

- @Disney - Star Wars

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- @PlankingPhotos

Any schema comes with an activation

trigger, a primary goal and an indefinite

number of subgoals

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 ?

You Wrong, You Die

- Hoang C. Huynh

- @PlankingPhotos

YOU FORGET THE ORIGINALS IN THE

MACHINE

#WRONG

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- Hoang C. Huynh

- @PlankingPhotos

YOU FORGET YOUR CREDIT CARD IN THE

READER

#WRONG

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- Hoang C. Huynh

- @PlankingPhotos

YOU FORGET YOUR CHANGE IN THE

VENDING MACHINE

#WRONG

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

You Wrong, You Die

- Hoang C. Huynh

EPIC FAIL

TRIGGER

DISASTER / ACCIDENT

DEFENSES

LATENT /ACTIVEFAILURES

MISSED OPPORTUNITIES

ABSENT DEFENSES

UNSAFE ACTS

REASON’s SWISS CHEESE MODEL

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#SOWRONGSPEAKING ABOUT DISASTERS

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THE ICEBERG

COLLISION

SHIPWRECK

NO AIDS

NO RESCUE

LACK OF BOATS

HIGH SEA

LOW VISIBILITY

TITANIC

#SOWRONGFAULT TREE ANALYSIS

You Wrong, You Die

- Hoang C. Huynh

- @Fox - The Simpsons

DESIGN FOR ERRORS

and Design for Failure or Design for Recovery

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

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

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DISC LOCK REMINDER

STRATEGIES

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- @FOX - Futurama

AUTOMATE ( YES WE ARE DOOMED )

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- @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 c o n t e x t , e . g . y o u 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.

You Wrong, You Die

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- @Unsplash

Distractions Incomplete or incorrect data Boredom Inadequate resources Cognitive overload Stress Illness Time pressure

TAKE IN CONSIDERATION

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• 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)

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PREVENT FEEDBACK WTF?

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TONIGHT WE DINE IN HELL

- @Warner - 300

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TONIGHT WE DINE IN HELL

BUT TOMORROW, I’M THINKING MCDONALDS

- @Warner - 300

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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

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NEARLY DEATH EXPERIENCE DOOR OPENING

- @Gizmodo

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- @Aetheros

Twitter: @aetherosLinkedin: in/hchuynhWeb: huynh.cc/blog

Slides will be available also on slideshare/aetheros

THANK YOU

You Wrong, You Die

- Hoang C. Huynh

Sources

http://www.slideshare.net/rezazarei125/human-errorhttp://www.slideshare.net/johnrooksby/cs5032-l5-human-error-1http://www.slideshare.net/johnrooksby/cs5032-lecture-2-failure-11609657http://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_errorhttp://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

You WRONG, You DIE #Codemotion 2014

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