Customer Reviews

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

5 star:		(14)
4 star:		(4)
3 star:		(2)
2 star:		(3)
1 star:		(0)

 

 

A perfect 6.0 on technical merit and artistic interpretation! `Set Phasers on Stun' is a fascinating series of 20 true stories about human factors, user interface design, and design-induced human error. Like a well-told fable used to enforce a useful truth, each story cleverly teaches you something interesting and instructive about the importance of the user interface in modern technology. Casey tells each story from the perspective of the user of the thing or system, so you can really see how people get sucked into a particular situation and understand the unfortunate consequences of the designer's decisions. There is a good blending of technical detail, emotion, and great writing. Addressed are, among other things, a crash in the Airbus computerized cockpit, a Soviet space fatality, assorted medical errors (`Set Phasers on Stun' - - the title story about a patient being zapped during a radiation treatment), the launching of a rocket inside a building in Sweden, a diving accident, the Bhopal disaster, and the supertanker Torrey Canyon. I was originally introduced to this book in an engineering class, and it really "turned on the light" as the saying goes.

Steve Casey has provided a valuable service to engineers, designers, and human factors professionals with his true tales of design-induced human error. These engaging stories range from disasters at sea and failures of space systems, to casualties caused by inappropriate procedures and the packaging of consumer items. The lesson from each story is different, but there is a single theme: the incidents could have been avoided if proper attention had been paid to the user during the design of the item or system. I have given copies of Set Phasers on Stun to several people to illustrate the importance of considering human limitations, as well as capabilities, when designing systems for human use. The book is an entertaining read for anyone. I highly recommend Set Phasers on Stun.

A number of friends had recommended "Set Phasers on Stun" to me as a good book on technology and human error. The 20 short stories in the book cover everything from the accidental launching of a rocket to some horrific accidents in hospitals. Each story is written in a way that takes the reader on an engaging, informative, and, quite often, wild ride. Casey's writing style works perfectly with this short story format. I highly recommend "Set Phasers on Stun" to anyone interested in design and technology, or anyone who likes reading very good short stories. The best part is that all of the events covered
by the book are true.

I first read Set Phasers on Stun (the first edition) as a textbook in one of my safety classes in college. In addition to being one of the most entertaining textbooks I ever had, it also had the deepest impact on me as far as illustrating how quickly and easily catastrophes can happen. Many of the cases presented in the book leave you shaking your head and wondering how such a simple mistake or oversight could lead to such horrific consequences.

I've used many of the cases in this book as examples when trying to make a point during my safety career. I would highly recommend this book to any engineer or safety professional. It's also entertaining reading for anyone with an interest in technology and complex systems.

This book is very entertaining and an easy read. It's made up of several short cases of how poor user design resulted in catastrophic results. For those who deal with design and human factors occasionally, the stories stay pretty fresh in the mind and serve as a great reminder to ensure reasonable effort is put into human factor design aspects of projects.

Extremely interesting accounts of tragedy and near catastrophe incidents. I was pleasantly surprised to see numerous references to the incidents discussed at the end of each article so I could follow up. Some cases tell accounts from the first person of people who have perished as a result of the design flaw / human error, and I had to wonder as to the accuracy of these particular cases - i.e. if they died, how did the author know what they were thinking (?). These are the minority of cases though. Written in a very simple style, which is very easy to read for the layperson or the expert wanting actual events to discuss in training, as examples of the importance of design, or persons simply interested in human error.

Casey compiles short descriptions of technological, engineering, and every day disasters. Although each story is very interesting, it leaves with reader with unanswered questions and a desire for deeper explantions. If you are looking for something light and entertaining, its an enjoyable book. If you are interested in understanding and preventing the tragedies discussed, look elsewhere.

This book of true short stories is an astonishingly fascinating collection of tales of oversights, errors, and design in the field of human factors. An extremely well-written book by ergonomist Steven Casey. I'm waiting for a sequel! You can't put it down. Each story is a book in and of itself.

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.

Author Casey serves up a smorgasborg of human and engineering failures that describe vividly the way things go wrong. Why would a farm worker electrocute himself by reaching for a high-tension wire with a 30-foot alumunum pipe? How could a nightclub serve up caustic dishwasher compound instead of a specialty drink? These stories and more are revealed in a readable, engaging way in this book. There is no explanatory text, however, explaining the roles of system-related barriers and controls to adverse events, so this book is more useful as a collection of case studies in a course on system safety rather than a textbook.