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Set Phasers on Stun: And Other True Tales of Design, Technology, and Human Error
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.
251 pages, Hardcover
First published July 1, 1993
24 people are currently reading
952 people want to read
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Displaying 1 - 30 of 38 reviews
October 29, 2018
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.
July 23, 2019
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.
November 13, 2014
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.
May 8, 2010
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.
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.
November 24, 2019
A bit morbid
December 31, 2022
I enjoyed the stories of these - in retrospect - easily avoidable catastrophes. The book certainly reads more like case studies in the sense that it presents the cases and asks the reader to pick out every point at which something went wrong, rather than a textbook of situations and solutions.
December 19, 2007
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.
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.
June 9, 2013
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.
December 5, 2022
This was required reading for my Engineering Psychology class and it was one of my favorite class-reads of all time. This book is composed of multiple stories about design errors that led to fatalities or similar situations. It taught me so much about airplanes, nuclear reactors, cars, and design environments that can cause detrimental consequences. Not only are the stories unsettling (in a good way), but they also make you consider your own environment and observe the design flaws in everyday objects that we use. I recommend this to anyone who loves short stories and wants to learn more about human factors.
January 14, 2025
A collection of anecdotes about failures in ergonomics. The stories are narrated but not analyzed, leaving the reader to come to their own conclusions. I can see why it works well in the classroom.
I learned about a disastrous convoy of naval ships that went aground off the central coast of California shortly after WWI. This was new to me and sent me to the library as the details related here about failures in navigation were obscure.
This was a problem with a few of the vignettes, for example the power failure in NYC and the mining of a Japanese ship off of Singapore. But each has a useful bibliography and despite the ambiguity, the central issue relating to design is clear.
I learned about a disastrous convoy of naval ships that went aground off the central coast of California shortly after WWI. This was new to me and sent me to the library as the details related here about failures in navigation were obscure.
This was a problem with a few of the vignettes, for example the power failure in NYC and the mining of a Japanese ship off of Singapore. But each has a useful bibliography and despite the ambiguity, the central issue relating to design is clear.
July 19, 2019
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.
October 23, 2020
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.
September 9, 2019
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.
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.
May 8, 2020
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
January 6, 2025
Read this on recommendation from a few co-workers. Easy to read and great for illustrating the chain of events that often lead to critical failures. Also shout out to MN for having not 1 but 2 companies involved in a mass poisoning episode.
December 21, 2017
excellent - must read
September 13, 2018
Exemplary, teaches one why human factors is such an important part of the product development process. Some of the stories are truly extraordinary....
November 18, 2018
Masterpiece.
January 3, 2020
It was a comical yet information book explaining the fatal effects of human error
Read
February 23, 2020Using for risk communication class case studies.
October 10, 2024
There were some interesting stories of disasters from failures, most of them due to unintended results of unexpected human/machine interactions, but I preferred Casey's previous book.
November 1, 2014
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).
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).
December 31, 2019
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
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
February 21, 2008
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.
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.
February 4, 2010
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!
December 22, 2011
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.
March 29, 2016
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").
October 12, 2013
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...
January 29, 2021
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.
Displaying 1 - 30 of 38 reviews