The document discusses lessons that can be learned from disasters about systems thinking and experience design. It notes that disasters reveal the complexity of real-world systems and defy expectations of accountability. Small changes can have big effects in complex, interconnected systems. The document advocates applying systems thinking principles to experience design, such as considering context, incentives, feedback loops, and experimentation to understand how systems work.

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

3. Rounding error

4. Rounding error or Programmer error?

5. Rounding error or Programmer error or System failure?

7. Why disasters? Reveal real-world complexity Defy our expectations about accountability and corrective action Cascade of ordinary failures Attract small-problem solutions Blame and shame

8. Management 101

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

10. What are systems? Economies Ecosystems Organizations Markets Projects Social Networks

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

12. Relevance to Experience Design Web is an ecosystem Systems within the web eBay Blogosphere Digg, Flickr, MySpace Cross-channel experiences

13. Value-Centered Design

15. Lessons Learned Cascade of ordinary failures Complex accountability Real-world tests

20. All Dead

24. “ 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.”

25. Lessons Learned Real-world tests Complex accountability Big problems have shared ownership Assumed safety nets can vanish easily Small changes  Big impact The Flywheel Effect

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

29. Eastern Flight 401

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

31. Successful Systems Transparency Quality over authority Shared ownership No goats (and few heroes) Team training Real-world tests

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

33. “ Screw around vigorously” - Tom Peters

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