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

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A disturbing share of technological disasters are caused by incompatibilities between the way things are designed and the way people actually perceive, think, and act. Structurally sound aircraft plummet to the earth, supertankers run aground in calm weather, and the machines of medical science maim unsuspecting patients - - all because designers sometimes fail to reflect A disturbing share of technological disasters are caused by incompatibilities between the way things are designed and the way people actually perceive, think, and act. Structurally sound aircraft plummet to the earth, supertankers run aground in calm weather, and the machines of medical science maim unsuspecting patients - - all because designers sometimes fail to reflect the characteristics of the user in their designs. Designers and the public alike are realizing that many human' errors are more aptly named designed-induced' errors. Most consumers experience the frustration of using many new products; amusing stories about programming a VCR, operating a personal computer, or finding the headlight switch on a rental car are heard in everyday conversation. The problems consumers experience with modern everyday things are shared by the users of large-scale technologies where the consequences of design can go well beyond simple matters of inconvenience or amusement. In the new second edition of Set Phasers on Stun' and Other True Tales of Design, Technology, and Human Error, noted designer and author Steven Casey has assembled 20 factual and arresting stories about people and their attempts to use modern technological creations. Although the operator or pilot usually gets blamed for a big disaster, the root cause can frequently be found in subtle characteristics of the device's human interface.' Technological disasters can often be traced directly to the interplay between people and the design of a device - - be it an airliner cockpit, the controls in an industrial plant, a spacecraft's instruments, a medical system, a nuclear reactor, or even a commercial dishwashing machine.


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A disturbing share of technological disasters are caused by incompatibilities between the way things are designed and the way people actually perceive, think, and act. Structurally sound aircraft plummet to the earth, supertankers run aground in calm weather, and the machines of medical science maim unsuspecting patients - - all because designers sometimes fail to reflect A disturbing share of technological disasters are caused by incompatibilities between the way things are designed and the way people actually perceive, think, and act. Structurally sound aircraft plummet to the earth, supertankers run aground in calm weather, and the machines of medical science maim unsuspecting patients - - all because designers sometimes fail to reflect the characteristics of the user in their designs. Designers and the public alike are realizing that many human' errors are more aptly named designed-induced' errors. Most consumers experience the frustration of using many new products; amusing stories about programming a VCR, operating a personal computer, or finding the headlight switch on a rental car are heard in everyday conversation. The problems consumers experience with modern everyday things are shared by the users of large-scale technologies where the consequences of design can go well beyond simple matters of inconvenience or amusement. In the new second edition of Set Phasers on Stun' and Other True Tales of Design, Technology, and Human Error, noted designer and author Steven Casey has assembled 20 factual and arresting stories about people and their attempts to use modern technological creations. Although the operator or pilot usually gets blamed for a big disaster, the root cause can frequently be found in subtle characteristics of the device's human interface.' Technological disasters can often be traced directly to the interplay between people and the design of a device - - be it an airliner cockpit, the controls in an industrial plant, a spacecraft's instruments, a medical system, a nuclear reactor, or even a commercial dishwashing machine.

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

  1. 4 out of 5

    Paul

    Excellent reading. At some point, Engineers developing perfect machines need to understand that they are operated by imperfect humans. Failure to allow for human interface is shown as a recipe for disaster.

  2. 5 out of 5

    Bill

    Each vignette is shallow, brief, and frustratingly matter-of-fact. Casey effectively builds suspense in each story (except for the five or so that are literally one page long and don't have time to) but then fails to deploy his actual HCI expertise to discuss the events, let alone have each incident add evidence supporting an overall thesis. There are many better books in this genre so I would definitely skip this one. Each vignette is shallow, brief, and frustratingly matter-of-fact. Casey effectively builds suspense in each story (except for the five or so that are literally one page long and don't have time to) but then fails to deploy his actual HCI expertise to discuss the events, let alone have each incident add evidence supporting an overall thesis. There are many better books in this genre so I would definitely skip this one.

  3. 5 out of 5

    Philip Hollenback

    This was a better book than the Atomic Chef (although I also enjoyed that one). There were a few interesting disaster stories in this book that I had not heard of before - such as the grounding of seven destroyers on the coast of California in 1923.

  4. 4 out of 5

    David

    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 constan 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 situation 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; 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 Objects 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 three stars, but no more than that.

  5. 5 out of 5

    Tracey

    Union Carbide Bhopal, the Idaho SL-1 Reactor and Soyuz 11 are among the design failure disasters discussed in this collection. The source of the title -- a fatal radiation dose that eventually killed the man who was expecting to be cured instead -- was his bravely flip answer to those who asked about the burns and scars. Despite the clever title, the stories themselves are rather workmanlike. Casey does attempt to provide some character and dialog (either excerpted from primary sources or based Union Carbide Bhopal, the Idaho SL-1 Reactor and Soyuz 11 are among the design failure disasters discussed in this collection. The source of the title -- a fatal radiation dose that eventually killed the man who was expecting to be cured instead -- was his bravely flip answer to those who asked about the burns and scars. Despite the clever title, the stories themselves are rather workmanlike. Casey does attempt to provide some character and dialog (either excerpted from primary sources or based on events), but the overall tone of the stories was somewhat depressing. Casey provides citations for each incident at the end of the chapter; as well as the occasional footnote to provide more information. It was a relatively interesting read, but interspersing the disaster stories with the occasional triumph over design (or at least failures that weren't catastrophic) would have been more enjoyable, IMHO. Recommended to those interested in human factors and design technology - but Casey is no Petroski or Norman.

  6. 4 out of 5

    Beth

    Really a 4.5. Amazing true stories. Quick read. Makes you appreciate the process and regulation we have. And that is difficult to protect against (mostly male) egos.

  7. 5 out of 5

    Doug Wilcox

    This book, like its "sequel," The Atomic Chef: And Other True Tales of Design, Technology, and Human Error, is just as interesting. One of the things I particularly like is each case study of human factors/technology/psychology gone wrong does not lecture about the probable causes or how the problems should be solved. The cases are much more thought-provoking that way. This book, like its "sequel," The Atomic Chef: And Other True Tales of Design, Technology, and Human Error, is just as interesting. One of the things I particularly like is each case study of human factors/technology/psychology gone wrong does not lecture about the probable causes or how the problems should be solved. The cases are much more thought-provoking that way.

  8. 4 out of 5

    Brian Miracle

    Not quite what I expected. I was expecting a book that dealt with somewhat more detailed analyses of various failures. Instead, this book dealt mostly with how misunderstanding of technology and/or human factors caused catastrophic failures. The book was entertaining, but I was hoping for some more detailed insight into the failure analysis process. I recommend this book, but more for its entertainment value than for its technical value.

  9. 5 out of 5

    Paulina Durán

    This is the 'Scary stories to tell in the dark' User Experience/HCI version. What's even scarier...is that all these stories are true O_o. Easy to read, although some stories are kinda intricate so one might get a bit lost (specially because there are very technical terms involved). However, this should be a recommended reading for every engineer out there. EVERY ENGINEER. This is the 'Scary stories to tell in the dark' User Experience/HCI version. What's even scarier...is that all these stories are true O_o. Easy to read, although some stories are kinda intricate so one might get a bit lost (specially because there are very technical terms involved). However, this should be a recommended reading for every engineer out there. EVERY ENGINEER.

  10. 4 out of 5

    Eric Brown

    Amazing stories that will pull you in and evoke all kinds of emotions — all surrounding issues related to Human Centered Design or lack thereof. I wish it had more current stories as this 2nd Ed. was 1998

  11. 4 out of 5

    Darryl Updegrove

    excellent - must read

  12. 4 out of 5

    Shasank Nagavarapu

    Exemplary, teaches one why human factors is such an important part of the product development process. Some of the stories are truly extraordinary....

  13. 5 out of 5

    Joe Leone

    It was a comical yet information book explaining the fatal effects of human error

  14. 4 out of 5

    Karla Kitalong

    Using for risk communication class case studies.

  15. 5 out of 5

    Michael

    dope

  16. 5 out of 5

    Chris Africa

    I could not finish this book. The writing had a very textbook feel, and I did not find it engaging.

  17. 4 out of 5

    Archana

    Very interesting book on major design flaws and human errors. I enjoyed reading it. I read one story a day and pondered over all the things that went wrong, everything that caused the outcome and what could have been done differently. The answers seem very simple, but the designs did not account for them. Some times we never know how a product/process is going to be used and under what circumstances. It is more critical to identify these for some more than others. But this book will definitely c Very interesting book on major design flaws and human errors. I enjoyed reading it. I read one story a day and pondered over all the things that went wrong, everything that caused the outcome and what could have been done differently. The answers seem very simple, but the designs did not account for them. Some times we never know how a product/process is going to be used and under what circumstances. It is more critical to identify these for some more than others. But this book will definitely create a new sense of awareness in the reader as to what one should think about when designing something. Highly recommend it for designers, engineers and product folks.

  18. 5 out of 5

    Alex Railean

    The book is a smooth introduction to the field of human-machine|computer-interaction, making it clear that little quirks can end up causing disasters. The narrative style might give the impression that the issues discussed are not serious, but all the chapters have references (+ I've encountered some of these cases in other sources). If you're interested in a more detailed account of these (or similar) events, have a look at `Inviting disaster` https://www.goodreads.com/book/show/2... I enjoyed rea The book is a smooth introduction to the field of human-machine|computer-interaction, making it clear that little quirks can end up causing disasters. The narrative style might give the impression that the issues discussed are not serious, but all the chapters have references (+ I've encountered some of these cases in other sources). If you're interested in a more detailed account of these (or similar) events, have a look at `Inviting disaster` https://www.goodreads.com/book/show/2... I enjoyed reading the book, and you will too, if you're in any way involved in the design of hardware or software interfaces (among other things).

  19. 5 out of 5

    Keith

    Once I started reading this book, I read it in a few days. Errors ranged from hubris, to poorly designed systems. Some of the errors were rather scary reading. There are other books that detail technology snafus. The one that seemed to start this genre is: Normal Accidents: Living with High-Risk Technologies Once I started reading this book, I read it in a few days. Errors ranged from hubris, to poorly designed systems. Some of the errors were rather scary reading. There are other books that detail technology snafus. The one that seemed to start this genre is: Normal Accidents: Living with High-Risk Technologies

  20. 5 out of 5

    Drnick

    The book briefly describes a number of engineering disasters and their causes. Apparently used in many classroom settings, the book is short on details. For one like me who is interested in the forensic details of post-accident investigations, this book was somewhat disappointing. Keep in mind that I read NTSB accident reports in detail out of pure curiosity, so the average reader may find this book quite a bit more satisfying that did I.

  21. 5 out of 5

    Sandra Strange

    What great stories of technological disasters, both personal and more widespread. From Bopal to Wall Street, one person's little mistakes in using technology can have horrendous consequences. These stories are always told from the point of view of one or more of participants, so the stories are immediate and fascinating in their detail. Great read, and learning too! What great stories of technological disasters, both personal and more widespread. From Bopal to Wall Street, one person's little mistakes in using technology can have horrendous consequences. These stories are always told from the point of view of one or more of participants, so the stories are immediate and fascinating in their detail. Great read, and learning too!

  22. 4 out of 5

    Holly

    It's a bit depressing to read stories over and over about things going wrong and people dying, but it's a good read for anyone in the human factors/usability field. It gives an idea of the importance of understanding the full system in the context of use and how little things can make a big difference. It's a bit depressing to read stories over and over about things going wrong and people dying, but it's a good read for anyone in the human factors/usability field. It gives an idea of the importance of understanding the full system in the context of use and how little things can make a big difference.

  23. 4 out of 5

    Caitlin Toliver

    My last quiz on this book at his other book (TAC) is tomorrow! Even though the stories were pretty tragic, I enjoyed reading them. Only complaint is that some of the stories, in both books, seemed drawn out; the same story could have been told in a few pages, not 25 (I'm looking at you, "Caught on Tape"). My last quiz on this book at his other book (TAC) is tomorrow! Even though the stories were pretty tragic, I enjoyed reading them. Only complaint is that some of the stories, in both books, seemed drawn out; the same story could have been told in a few pages, not 25 (I'm looking at you, "Caught on Tape").

  24. 4 out of 5

    Angelo

    The background to all those screwups you've heard about in the past (does Therac ring a bell?), but not a very entertaining read. After some 12 stories (there are 20 in total) you feel where "this is going", and feel sorry for the main characters already... The background to all those screwups you've heard about in the past (does Therac ring a bell?), but not a very entertaining read. After some 12 stories (there are 20 in total) you feel where "this is going", and feel sorry for the main characters already...

  25. 5 out of 5

    Nina Vaught

    Even if you are not into Human Factors Research and Usability, this is a fascinating and entertaining set of real-life short stories about ridiculous (and often deadly) results of not considering the human element when designing technology.

  26. 5 out of 5

    Connor

    Really liked this book. It serves its purpose very well and the stories are extremely interesting!

  27. 4 out of 5

    Polly ?

    Some of the stories I wished were fiction due to their grusome outcomes. This book really makes you take a second look at how much you take technology for granted.

  28. 5 out of 5

    Larry

    A very dark set of true stories where poor technology design resulted in terrible accidents... often fatal. These are cautionary tales, not bedtime stories.

  29. 5 out of 5

    Reader Girl

    A quick, fascinating read.

  30. 4 out of 5

    Trendy Chen

    This was the only textbook that I enjoyed reading. This book goes beyond as a textbook. Anyone can pick it up and I recommend they do, especially for engineering students.

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