How to Avoid Disaster
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This document discusses how to learn from massive failures by examining disasters through a systems perspective. It provides examples of disasters in aviation and healthcare to highlight lessons about complex accountability, small changes leading to big impacts, and the importance of transparency, quality over authority, shared ownership and team training in successful systems. The document recommends understanding what influences solutions, considering feedback in design, helping clients find leverage points, and knowing when issues are beyond solution.
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How to Avoid Disaster
- 2. How to avoid disaster L earning about UX by looking at massive failures CanUX September 14, 2006 Banff, Alberta
- 3. Why disasters? Reveal real-world complexity Defy our expectations about accountability and corrective action Cascade of ordinary failures Attract small-problem solutions Blame and shame
- 7. What is a system? Collection of “stuff” Dynamic, complex, interdependent relationships Can't be decomposed into linear processes Can't be separated from the environment or context in which they occur Small changes big effects
- 8. What are systems? Economies Ecosystems Organizations Markets Projects Social Networks
- 9. Agenda Talk about a few disasters Lessons learned Successful systems Mindset
- 11. Rounding error
- 12. Rounding error or Programmer error?
- 13. Rounding error or Programmer error or System failure?
- 14. Lessons Learned Real-world tests Complex accountability
- 17. All Dead
- 20. Lessons Learned Real-world tests Complex accountability Big problems have shared ownership Assumed safety nets can vanish easily Small changes Big impact
- 24. NASA Research (1979) Primary cause of most aviation accidents: Leadership Decision-making Interpersonal communication Led to teamwork training for flight crews Reporting of near misses
- 25. Teamwork training “ A state medical board has fined a surgeon and an anesthesiologist $10,000 each for brawling in an operating room while their patient slept…” “ A nurse monitored the patient as the doctors fought”
- 26. Successful Systems Transparency Quality over authority Shared ownership No goats (and few heroes) Team training Real-world tests
- 27. Lessons for UX Understand what influences your solution Consider feedback as a design parameter Help clients find leverage points Know when you’re at a brick wall Unintended consequences
- 28. Facebook “… Facebook's feedback from users comes in the form of emails to its customer-service email address, which the company's product-development team reviews weekly. But the company typically doesn't solicit feedback by showing features to users before launching them ." Wall Street Journal , September 7, 2006
- 33. Questions? Stories? Email: [email_address] URL: http://atomiq.org/etc/canux_2006.pdf