When No Communication is Best: Speed Skating, Morphine Overdoses and the Wings Fall Off Button
Occasionally, though, people go to the other extreme and design their solution so that without very robust communication some errors are very likely. I call these design flaws “wings fall off” errors in honor of the classic Gary Larson cartoon showing someone sitting in an airplane fumbling for the recline button and touching instead the “wings fall off” button, unwittingly causing a disaster. We laugh because no airplane designer would even have a “wings fall off” button and it certainly wouldn’t be next to the recline button*.
But in many real life cases people do exactly the same thing, designing consequences that are fatal – sometimes quite literally – for simple errors that are very likely to occur. There was a fascinating example of this process in Vancouver this week when Dutch speed skater Sven Kramer was disqualified after winning his second gold medal because of an error in the crossover from one lane to another.
This is poor design because if it is so critical to make a lane change after an exact number of laps then there should be better mechanisms for avoiding errors, like having special signs warning when a change is needed or an official pointing the right lane. Alternatively they can leave the same lane confusion but soften the consequences, adding a time penalty instead of disqualifying the athlete. In this case Kramer was so far ahead that a time penalty would not have changed the result and the consensus would have been that the medal was awarded fairly.
A more tragic example of this kind of designed in error is the 2008 case of a doctor in the UK who administered a lethal dose of diamorphine painkiller to a patient on what was his first -- and obviously also last -- day on the job. He was fired for incompetence but in reality you could argue that it was not entirely his fault, an aspect of the story that only emerged into the recent inquest. In the standard issue doctors bag in the area there was a 100mg ampoule of diamorphine, the inquest was told, while the normal therapeutic doses range from 5 to 10mg. There had been several near misses in the past so a warning was issued to doctors about giving large doses, but giving doctors a handily injectable lethal overdose is the medical equivalent of the “wings fall off” button and should never have happened. This death could have been avoided very simply by giving doctors a box of 5mg ampoules so that lethal overdoses would require a conscious decision to inject an unusual number of ampoules.
Communicating important safety messages is clearly something that must be done carefully, but even more effective is the design of robust systems and processes that work even when people have not read the warning labels. For this reason sometimes the best communication is no communication -- not to tell the user what to do, but to ensure that the system designer understands that the best form of warning is one that is not needed.
* I would like to include a copy of this cartoon or link to a copy on an official site but Gary Larson does not allow his work to be used in electronics form. You can find the cartoon -- and thousands more -- in the excellent but expensive book set "The Complete Far Side 1980-1994".