Category: Human Factors Engineering

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Complex, critical systems programs are under real pressure to deliver faster. The fastest teams I’ve worked with get their speed from first-time quality; going fast in the wrong direction is ultimately more costly in dollars, schedule, and—most impactfully—mission effectiveness. “Move fast and break things” was Facebook’s internal motto for years. When the thing that breaks is the ability to repost a Minions meme and the potential upside is a new strategy for keeping billions of eyeballs engaged for longer, it’s a worthwhile tradeoff. Facebook outgrew the motto in 2014, changing to “move fast with stable infrastructure”. Defense and other critical …

Move Fast and Validate Things Read more »

Our world and our systems are safer than ever. A major reason why is that we’ve learned from prior mistakes. Many of our practices, rules, and standards are “written in blood” from past, tragic failures. We learn so that we don’t repeat the same mistakes. Of course, we first identify the proximate causes—the specific events directly leading to a casualty. To truly learn, we must take a step back to examine the larger context: what were the preceding holes in the Swiss cheese, and how do we account for them in our systems engineering practice? This approach is increasingly important …

Written in Blood: Case Studies of Systems Engineering Failure Read more »

One of my favorite items in my small model collection is a 1:34 scale Grumman Long Life Vehicle (LLV) with sliding side doors, a roll-up rear hatch, and pull-back propulsion. The iconic vehicle has been plying our city streets for nearly 40 years, reliably delivering critical communiques, bills, checks, advertisements, Dear John letters, junk mail, magazines, catalogs, post cards from afar, chain letters, and Amazon packages.

The Navy installed touch-screen steering systems to save money. Ten sailors paid with their lives. ProPublica Ten sailors died after the crew of the destroyer USS John S. McCain lost control of their vessel, causing a collision with the merchant tanker Alnic MC. There was nothing technically wrong with the vessel or its controls. Though much of the blame was put on the Sailors and Officers aboard, the real fault rests with the design of the Integrated Bridge & Navigation System (IBNS).

The term ergonomics was coined by Wojciech Jastrzębowski in 1857 to mean “the science of work” with the goal of improving productivity and profit. He described the importance of physical, emotional, entertainment, and rational aspects of the labor and employee experience, but the context was squarely on factory-type production. Over time, this has evolved into two, slightly different definitions.

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