The Atomic Chef: And Other True Tales of Design, Technology, and Human Error

by Steven Casey

i Prologue 1 The Atomic Chef The disturbing story behind one of history’s worst nuclear criticality accidents.2 The Embryo Imbroglio A deviation in procedure at a Manhattan fertility clinic results in a big surprise for two patients.3 Signal Detection How airline security officials in Paris classified — and misclassified — “shoe bomber” Richard Reid.4 Out of Synch The Canadians cry “foul” at the Barcelona Olympics when an American wins the gold, but the problem lies with the user interface of the judge’s keypad.5 Death on Call A US Special Forces team in Afghanistan mistakenly targets a precision-guided bomb on their own position.6 Picture Window Astronauts race to locate the source of a threatening air leak aboard the International Space Station.7 Event Horizon A harmless MRI scan at a New York hospital turns to tragedy for a young patient when good intentions interact with an invisible force.8 Freeway Driver Artist Richard Ankrom takes matters into his own hands to enhance a confusing freeway sign.9 Caught on Tape The nightmare flight of AeroPeru 603 off the coast of South America, and its surprising cause.10 911, More or Less A chain of errors in an emergency dispatch center has tragic consequences for a Los Angeles family.11 ATM It’s Thanksgiving evening, and one unfortunate bank customer in New Jersey contemplates spending the holiday locked inside an automatic teller booth.12 Under the Radar Maintenance errors and low load estimates bring down a commercial airliner.13 Safer than Safe How early batches of Salk polio vaccine actually spread the dreaded disease rather than prevent it.14 Rhymes and Reasons The ergonomics involved in musician John Denver’s final flight.15 A Kid in a Car A toddler in Kansas is strangled by an electric-powered vehicle window of a particular design.16 The Perilous Plunge This amusement park ride is much too perilous for one unfortunate customer.17 Titanic’s Wake Two Chicago dockworkers witness a maritime calamity of unthinkable consequence.18 Driven to Distraction A French motorist discovers yet another form of driver distraction.19 Negative Transfer NASA test pilot Milt Thompson faces certain death unless he can quickly determine why his experimental aircraft is wobbling out of control.20 End Game Greek shipping magnate Pandelis Sfinias contemplates his own fate and the causes of the sinking of the Express Samina ferry.

Genres: Nonfiction, Design, History, Academic, Engineering

288 pages, Hardcover

First published June 1, 2006

Reviews

[Paul · Rating 4 out of 5]

Another excellent read for anyone interested in the link between design technology and human error. A must for anyone involved in design safety. On a sad note, very upsetting to read how famous country singer John Denver died. As soon as the design of the Rutan LongEZE was described, you could see the accident coming. If only he had seen it too

[Philip Hollenback · Rating 4 out of 5]

I enjoyed this book thoroughly. Don't expect a lot from it - it's basically a collections of short stories about various disastrous events (some comical, some horrible). I'm assuming that each story is factual since there are many citations after each one.

There's not a lot of analysis after each story, the book just focuses on the events themselves. Still, if you like reading about plane crashes this one is for you.

[Anne Gray · Rating 2 out of 5]

Not as good as its predicesor, Set Phasers on Stun, This compendium of technology design, maintenance, and process failures is still an interesting read for anyone interested in Human Factors and in understanding how systems fail.

[Michael Duah · Rating 3 out of 5]

Amazingly depressing. If you have ever wanted to be deathly afraid of ordinary situations, this book is for you.

[Jarek · Rating 3 out of 5]

Content warning: a lot of people die in this book, and by the third story you figure that people will die in most stories - not the best read for those who get stressed by the tension of build-up to death

I had this as a text for a cognitive ergonomics course, and re-read now. It presents stories of accidents in chronological order, often from the point of view of operators/pilots/humans directly interacting with the systems. There is enough detail to be able to analyze the accidents from a human factors / ergonomics / design point of view, but usually no actual analysis. Still, all the details are there, and if the detail seems weird to include at first, it's probably important to the story later.

It seemed a good overview and collection of sample cases, but without the analysis it's probably not the best as a standalone resource - you're better off with a book or an instructor to explain the concepts beforehand and answer possible questions after reading.

[Doug Wilcox · Rating 4 out of 5]

This book, the "sequel" to Set Phasers on Stun: 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.

[Venkata Ashish · Rating 3 out of 5]

Although the book does provide a number of cases with a vast variety, there are many parts where the stories could have been completed with much less information, they seem to be dragging on. On the whole, the book does make for good supplement reading material for any class on Human Factors Engineering, there are various moments in the book where one can easily see how a little alteration to the existing system could have prevented the mishap from occurring at all.

[Lauren · Rating 4 out of 5]

This is an enlightening read about the design/technology of our modern world. But, I wish the author had not left the reader quite so alone for discussing the human factors design issues (basically, although he does is present the problem and the consequences). I know he purposefully did that, but as a reader I would appreciated at least a little guidance. It was engrossing, often because the reality of what can go wrong is so scary! I do not recommend reading the sections about planes whilst riding a plane…. :P haha a poor choice on my part.

[Julia · Rating 4 out of 5]

Interesting insights into some of the most avoidable instances brought to us by human-technology interaction. Normally I would find these also funny, but he manages to beat the fun out of the stories with minutia. We are covering this book in our Friday afternoon Human Factors class, and now we refer to it as 'Black Friday' because there are always stories of death and destruction. But fear not, a few did survive!

[Tandi · Rating 5 out of 5]

a good collection of real tales of human error - which the author calls system design error - since this is my area of expertise, it was great to have the material displayed in a very entertaining and readable way, like a story being told instead of a case study of facts

[Reader Girl · Rating 5 out of 5]

I'm not a particular fan of short stories or nonfiction, but I loved this book. Casey is a great writer, and it's fascinating to learn how a simple design flaw can be so devasting.

[Brian · Rating 5 out of 5]

I learned about how easy it is for people to make errors with how design and technology.