1.
Massive Failure What Disasters Can Teach Us About Experience Design 7 th Society and Information Technologies Encounter November 13, 2006 Santiago, Chile

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<ul><li>Rounding error </li></ul>

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<ul><li>Rounding error </li></ul><ul><li>or </li></ul><ul><li>Programmer error? </li></ul>

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<ul><li>Rounding error </li></ul><ul><li>or </li></ul><ul><li>Programmer error </li></ul><ul><li>or </li></ul><ul><li>System failure? </li></ul>

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Why disasters? <ul><li>Reveal real-world complexity </li></ul><ul><li>Defy our expectations about accountability and corrective action </li></ul><ul><li>Cascade of ordinary failures </li></ul><ul><li>Attract small-problem solutions </li></ul><ul><ul><li>Blame and shame </li></ul></ul>

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Management 101

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What is a system? <ul><li>Collection of “stuff” </li></ul><ul><li>Dynamic, complex, interdependent relationships </li></ul><ul><li>Can't be decomposed into linear processes </li></ul><ul><li>Can't be separated from the environment or context in which they occur </li></ul><ul><li>Small changes  big effects </li></ul>

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What are systems? <ul><li>Economies </li></ul><ul><li>Ecosystems </li></ul><ul><li>Organizations </li></ul><ul><li>Markets </li></ul><ul><li>Projects </li></ul><ul><li>Social Networks </li></ul>

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Do Systems Matter? <ul><li>GM closes plant in Fremont, California (1982) </li></ul><ul><ul><li>Worst quality record </li></ul></ul><ul><ul><li>Worst labour relations </li></ul></ul><ul><ul><li>Highest employee absenteeism and drug use </li></ul></ul><ul><li>Toyota opens Fremont plant in 1984 </li></ul><ul><ul><li>Hires 80% of GM’s workforce </li></ul></ul><ul><ul><li>Outstanding quality record </li></ul></ul>

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Relevance to Experience Design <ul><li>Web is an ecosystem </li></ul><ul><li>Systems within the web </li></ul><ul><ul><li>eBay </li></ul></ul><ul><ul><li>Blogosphere </li></ul></ul><ul><ul><li>Digg, Flickr, MySpace </li></ul></ul><ul><li>Cross-channel experiences </li></ul>

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Value-Centered Design

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Lessons Learned <ul><li>Cascade of ordinary failures </li></ul><ul><li>Complex accountability </li></ul><ul><li>Real-world tests </li></ul>

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All Dead

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<ul><li>“ Good-to-great transformations do not happen overnight or in one big leap. Rather, the process resembles relentlessly pushing a giant, heavy flywheel in one direction.” </li></ul>

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Lessons Learned <ul><li>Real-world tests </li></ul><ul><li>Complex accountability </li></ul><ul><li>Big problems have shared ownership </li></ul><ul><li>Assumed safety nets can vanish easily </li></ul><ul><li>Small changes  Big impact </li></ul><ul><ul><li>The Flywheel Effect </li></ul></ul>

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http://www.boeing.com/commercial/safety/pf/pf_accident_rate_history_cht.html

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Eastern Flight 401

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NASA Research (1979) <ul><li>Primary cause of most aviation accidents: </li></ul><ul><ul><li>Leadership </li></ul></ul><ul><ul><li>Decision-making </li></ul></ul><ul><ul><li>Interpersonal communication </li></ul></ul><ul><li>Led to teamwork training for flight crews </li></ul><ul><li>Reporting of near misses </li></ul>

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Successful Systems <ul><li>Transparency </li></ul><ul><li>Quality over authority </li></ul><ul><li>Shared ownership </li></ul><ul><li>No goats (and few heroes) </li></ul><ul><li>Team training </li></ul><ul><li>Real-world tests </li></ul>

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Bringing Systems Thinking to Experience Design <ul><li>Context, context, context </li></ul><ul><li>Ignore boundaries </li></ul><ul><li>Create simple models of systems </li></ul><ul><ul><li>Actors, objects, policies </li></ul></ul><ul><ul><li>What influences what? </li></ul></ul><ul><ul><li>What/where are the incentives? </li></ul></ul><ul><ul><li>Are there leverage points? Feedback loops? </li></ul></ul><ul><li>Experiment, experiment, experiment </li></ul>

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“ Screw around vigorously” - Tom Peters

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Questions? Email: [email_address] URL: http://atomiq.org/etc/massive_failure_chile_2006.pdf