This document discusses how to learn from massive failures by examining disasters through a systems perspective. It provides examples of disasters in aviation and healthcare to highlight lessons about complex accountability, small changes leading to big impacts, and the importance of transparency, quality over authority, shared ownership and team training in successful systems. The document recommends understanding what influences solutions, considering feedback in design, helping clients find leverage points, and knowing when issues are beyond solution.

2. How to avoid disaster L earning about UX by looking at massive failures CanUX September 14, 2006 Banff, Alberta

4. Management 101

5. Management 101

6. Management 101

17. All Dead

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

23. Eastern Flight 401

33. Questions? Stories? Email: [email_address] URL: http://atomiq.org/etc/canux_2006.pdf