you wrong, you die #codemotion 2014
DESCRIPTION
An UX talk about Human Errors, Errant Behavior and Design. A small and humble talk presented at Codemotion 2014 in Rome: nothing new or disruptive, but some stuff "who knows why" usually ignored but so useful for UX folks and Developers as well.TRANSCRIPT
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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
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ROME 11-12 April 2014
Hi, I’m Hoang!
I Am Learning GermanI Am Easily BoredI Love Technologies
I Design Experiences
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ROME 11-12 April 2014
Hi, I’m Hoang!
I Am Learning GermanI Am Easily BoredI Love Technologies
I Design ExperiencesHOW PEOPLE WORK
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
USUALLY
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
WE CREATE STORIES
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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
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
AND USABILITY ISSUES
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @CW - Arrow
WE MUST BE SOMEONE ELSE
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @CW - Arrow
WE MUST BE SOMETHING ELSE
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
BUT “SOMETIMES”WE HAVE TO DESIGN
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
FOR PEOPLE WHO ARE “VOLUNTEERS”
AKA EMPLOYERS
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Landmark - Captain Power and the Soldier of the Future
WE HAVE THE POWERTO BRING THEM
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Warner - Constantine
HELL
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Warner - Constantine
OR HEAVEN
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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 METRICSWE HAVE TO DEAL WITH
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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
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
#BOOBS
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
#KITTENS
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh- Speaker’s name
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
THE HUMAN ERROR
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
30 ADErrare humanum est, !
perseverare autem diabolicum, et tertia non datur
Lucius Annaeus Seneca, Philosopher
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
1711To err is human !
To forgive, divine
Alexander Pope, Poet
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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
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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
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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.
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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
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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
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Warner - Inception
WE NEED TO GO
DEEPER
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- Courtesy of Wikipedia
AN ERROR IS NEVER #WRONG BY PER SEA DISASTER
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Fox - The Simpsons
AN ACCIDENT#WRONG
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
#NSFW- @DamnYouAutoCorrect
DUCKING AUTO CUCUMBER!
A DISTRACTION#WRONG
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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)
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @NSF DBA
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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
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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
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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
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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
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
- @Gizmodo
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ROME 11-12 April 2014
You Wrong, You Die
- Hoang C. Huynh
NEARLY DEATH EXPERIENCE DOOR OPENING
- @Gizmodo
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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.
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ROME 11-12 April 2014
You Wrong, You Die
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1969To err is human !
but to really foul things up you need a computer.
Paul Ehrlich , Scientist
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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
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ROME 11-12 April 2014
You Wrong, You Die
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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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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
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You Wrong, You Die
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Skill based
- @Huffpost #WRONG
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ROME 11-12 April 2014
You Wrong, You Die
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Rule based
WHERE ARE THE TOILETTES? On the right, over there
:| No…#WRONG
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ROME 11-12 April 2014
You Wrong, You Die
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- @Marvel - The Avengers
Knowledge based (negative)
CAN YOU RUN A FLIGHT DIAGNOSTIC ON THE MARK IV?
#MAYBEWRONG
Yes… but…
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ROME 11-12 April 2014
You Wrong, You Die
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Knowledge based (positive)
“ALL THE JAEGER ARE DIGITAL”#WRONG! Gipsy’s Analog, Nuclear!
- @Warner Bros - Pacific Rim
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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."
GEMS Generic Error Modeling System
Reason 1990
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ROME 11-12 April 2014
You Wrong, You Die
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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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You Wrong, You Die
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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
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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%
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ROME 11-12 April 2014
You Wrong, You Die
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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.
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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
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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
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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
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ROME 11-12 April 2014
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- 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…
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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
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- @PlankingPhotos
Any schema comes with an activation
trigger, a primary goal and an indefinite
number of subgoals
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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 ?
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- @PlankingPhotos
YOU FORGET THE ORIGINALS IN THE
MACHINE
#WRONG
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- @PlankingPhotos
YOU FORGET YOUR CREDIT CARD IN THE
READER
#WRONG
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- @PlankingPhotos
YOU FORGET YOUR CHANGE IN THE
VENDING MACHINE
#WRONG
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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
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EPIC FAIL
TRIGGER
DISASTER / ACCIDENT
EVENT
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
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- @Fox - The Simpsons
DESIGN FOR ERRORS
and Design for Failure or Design for Recovery
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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
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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.
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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
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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