holidays, hammocks, work experience and summer.

One of these things is not like the others….

Just kidding… I seem to be enjoying them all equally.

Along with the normal resolution to get fit, enjoyment of the wonderful hammock and a healthy dose of doing purely nothing except for listening to Taylor Swift’s new album, I’ve been invited to do work experience, of sorts. It’s not what school calls ‘work experience’, and I’m glad about that! It’s big and exciting and gives me a chance to put some of what I’ve learnt into practice, and hopefully see some good results. Besides all that, I’m always up for a challenge.

Holidays are great, but it’s possible to let your mind get complacent and us uni students have a powerful tendency to memorise things for assignments and exams and forget them immediately after (perhaps to make room for more knowledge), and that is the LAST thing I want to do.

Stay tuned, we’ll see what develops!

happy endings and new horizons.

It’s that time of year again-  the time when I’m tearing my hair out over group assignments, wishing I hadn’t slacked off so much after the mid-term break, and trying to wrap my head around all the tasks I’ve got left.

The term is all too quickly coming to an end.

I’m beginning to figure out that half the function of university is teaching you how to think (systematically, logically, anatomically, creatively, inquisitively), and the other half is how to apply it. If that’s the system goal here, it’s working well! It’s obvious, and my lecturers have done something right here, because the above statement is self-confirming… I just reflexively thought of a university as a system.

Some interesting things I’ve learnt this term:

• My perspective has been changed regarding every accident- it’s almost always part of a larger system that should be considered, for a responsible and accurate analysis.
• There is never just one way of looking at something, displaying it or analysing it.
• I’ve rediscovered that I function much better as the leader of a group or team than as a follower- whether that’s good or bad I can’t decide- it’s certainly a lot more work.
• Every term I slack off horribly between the mid-term break and exam week, I need to find a way to deal with that…
• I’m actually pretty alright at memorising the endless anatomy and physiology information!
• I know how to act around an accident scene, what photos to take and what to do in a legal sense.

…and it just keeps getting better. This term has really been fantastic, and taught me things I’ll still use years and years from now.

I’ll blog agin when all this chaos is over, but until then, onward and upward!

code can kill.

No, I’m not a anti-technology hippie with tie-dye pants and hairy underarms, I’ve just read (again!) the incredible story of how at least 6 people were zapped with high-powered radiation beams, and how three of them died as a result. Now if that’s not a decent system failure, ‘slap ma face with the side of a hawg’, or so says my uncle who likes to think he’s Canadian.

The story I’m referring to is that of the Therac-25, a radiation machine with two modes: electron-beam therapy (low doses of electrons over a short period of time) and megavolt X-ray therapy (using the full power of the machine by delivering X-rays produced by high-energy electrons in a powerful beam. A metal plate spreads the beam out before contact with the patient, and lowers the intensity).

The weak links were the software in the machine and the user interface. The code was sloppy and some of it was reused from a previous machine which had hardware components to cover faults in the software, whereas the Therac-25 was more software-based. Furthermore, when a particular set of commands was entered too quickly, the machine malfunctioned and it resulted in activating the high-powered and dangerous X-ray mode, but without the metal plate in place. There was nothing to tell the operator that anything was wrong… except for the patients screaming, jumping off the table and complaining of electric shocks. But according to the display, they had only recieved one-tenth of the dose.

They clued on when the patients started dying of massive radiation poisoning. The first victim was Ray Cox, who had several blasts of more than 125 times the prescribed dose.

So that’s the backstory, let’s apply it to the WorkSafeBC ‘People,  Workplaces and Management’ model. Sounds boring, but it’s a good way to show all the different elements of a system that came together to make an accident.

You can see how this model gets very crowded in a complex accident.

There you have it! You can see how all those elements, when combined, make a deadly accident.

And for a final note: Ray is such an ironic name to have in this incident.

safe design… in pen lids.

Last night at dinner, I was talking about the case study we had been discussing in class, which was related to safe design (also known as Prevention through Design, or PtD). Basically, the concept is that accidents should be prevented by better design “at the source”, rather than expensive and difficult ways of managing hazards later in the system’s life.

The case study involved a fatal accident which could have been avoided, had the designers of the equipment just thought about the context in which it would be used, and put themselves in the shoes of the operators. It’s an idea I can really see the sense in.

Dad, being a senior St Johns volunteer, had an interesting  example of safe design in the real world- almost all pens sold these days (that have caps) have a hole in the cap. Apparently, this is because pen lids are the perfect size to lodge in the trachea and are a major cause of choking to death.

Try not to test the ‘safe’ theory!

Cue the family all grabbing pen lids and trying to whistle/breathe through them.

Bottom line- it works. You may pass out, but you won’t die.

I thought it was so amazing how you can see evidence of safe design in something as simple as pen lids with a little hole in the top. Solutions don’t need to be complicated and expensive. Furthermore, how amazing is it that so many accidents don’t happen, and so many objects aren’t hazardous?! We can get so caught up looking at the exceptions, and that’s all well and good in its own time, but one of the reasons we’re still alive is probably just because someone’s thought of a way to make the things we use safe, back when the concept was born.

Can you think of any other weird safety features?

the circle of liiiiiiiiiiiife!

Nants ingonyama bagithi Baba, Sithi uhm ingonyama
(You always got the words wrong, didn’t you.)

The sun dawns over the African landscape, with a single voice crying out in Zulu, joined by others in a chant, deepening into a song that suddenly becomes suspiciously English and Disney-like. Yes, it’s the introduction of Lion King in my head. Only this time, it doesn’t go to a little ball of fluff on Pride Rock, it’s the circle of life of…

my laptop.

Don’t give me a look of disgust. It’s true, machines and systems have life cycles too! Let me explain.

Concept to detailed design:

This stage involves the lovely people at Hewlett-Packard sitting down and deciding how they want to design my laptop and according to their website (http://www8.hp.com/us/en/hp-information/environment/mobile-design.html), making it easy to recycle, non-toxic, energy saving and environment-conserving. At this stage my lovely laptop is no more than a few words on paper and an idea in someone’s head- although you should never underestimate the power of that.

Things that can go wrong at this level include designing it so that it is difficult to use (such as placing the trackpad in such a way that the mouse moves when the user is trying to type, or making the keys too big or too small, or not giving it enough memory or battery or hard drive space, or making it too heavy). These will impact on later stages of the cycle, so it’s an important formative stage.

Construction:

At this stage the idea becomes a tangible, physical thing, and should be constructed with maximum efficiency and care, especially with something of value. My laptop for instance has been constructed with a minimum of number and different types of materials, and without using substances that could pose a risk to workers constructing it.

Failures here can occur if a laptop is mistakenly put together incorrectly on the assembly line, or a part is faulty from the manufacturers. Even if your planning and design is flawless, this can still happen through errors.

Commissioning:

The initial rollout of the machine: it involves logistics, prices, politics with stores that may sell this laptop, and so on. Failures can happen when a region fails to receive the laptops in a timely manner because transport was handled inefficiently, or a store is not on good terms with HP, or the RRP (recommended retail price) doesn’t end up making any real profit. The initial days and weeks of commissioning something like a laptop also tend to reveal the bugs that designers and testers may have missed.

Operating/Maintaining:

This is the part where the real user finally makes an entrance! As I’m typing this on my lovely laptop, I can safely say I don’t have any problems with it (besides the fact that the battery runs out in a few hours due to accidentally leaving it plugged in for longer than it needs every so often). It beeps when it needs plugging in, but it would be nice to have a feature that makes a noise when it’s fully charged. In any case, I may not have a problem with operating or maintaining it, but never fear, failures can still occur.  These could look something like non-tech-savvy users thnking it’s too complicated, HP having to respond to and fix bugs, as well as providing support and software updates, and the user having problems with operation (or maybe even battery life).

Decommissioning:

Sadly, every laptop meets  its end. It involves HP removing the design from production, communicating to the stores that the product has been deleted, and finishing distribution of existing stock. On the other end, when the user’s laptop is less than adequate for normal use, they may recycle it, shoot it, smash it or do whatever floats their boat, and then get a new one. Failures and difficulties at this level include HP failing to communicate with stores, users not wiping the hard drive in which case identity theft may be possible, and incorrect or difficult recycling at the plant.

For all you visual kids.

So there you have it, a whole system life cycle. Fairly complicated and taken for granted in the case of most things we use and handle, every day.

I just hope the end of my laptop doesn’t involve it hanging off my desk by its non-slip pads while its successor snarls “Long live the King.”

work before play? pft.

I was flicking through notes from my Intro to Investigative Methods lectures, and happened across a word written in bold purple ink.

There you have it- PLAY.

Why it was written down was this- my lecturer refers to investigating accidents as ‘playing’. For example:

“In some countries they won’t let you go play at a site unless you have your vaccinations up to date.”

“If you’re in an investigation agency, you really don’t know what technology you’re gonna be playing with.”

… and so on. I think that is pretty much one of the coolest things ever. Why shouldn’t work be play? Why should we do something that isn’t fun, or making our brains work, or helping someone? Admittedly, this is coming from someone writing a non-assigned blog post when there’s several that I should be writing. But I digress.

I  can’t believe that I’m heading for a career where the old hands at it can still refer to it as ‘playing’. I hope that that’s always the case, even though some days might be challenging on my emotions or brain or body, I hope that at the end of the day, I still love what I’m doing and it seems like more play than work.

Future career, here I come!

 

what subway and tripods have to do with each other.

I walked into the lunchroom today for my half-hour break at work, boiled the kettle and sat down to have a nice Cup-A-Soup for lunch (in a new flavour!). Yay! Yay? no. It was DISGUSTING. Luckily, I had my card and it’s a 15-second walk to Subway. Talk about burning off your lunch calories.

As I was waiting and watching the people in front of me have their chicken teriyaki toasted in the little Subway sandwich oven, my brain began to tick over, again. First of all, that beeping would drive me absolutely insane (assuming of course that I’m not already). But to turn it off could lead to disaster… cue dramatic music.

Here’s our scenario:

A customer becomes very ill from eating at a restaurant. The usual barrier to this happening is cooking the food for long enough.

However, rather than stopping at ‘the food wasn’t cooked long enough’ and ‘teach the cooks to cook longer’, the Tripod method goes a bit deeper. Why did the barrier fail?

We find that it is because the staff turned the timer off. Again, we could stop at ‘turn the timer back on!’, and again we can go deeper. Why did they turn it off? It turns out that the alert when the timer finished was too loud, constant and invasive in the small kitchen.

Put this all in a flowchart, and voila, it’s a Tripod analysis! (So named, I assume, for the three ‘legs’).

Our scenario, in Tripod analysis format.

 

From this, I would conclude that the designers of the oven failed to take into account the frequency of use which it would receive, and thus the alarm is a design fault. I would also recommend that the alarm is changed to become still audible but not as loud. Following this, it should be turned back on or the option to turn it off removed completely.

 
So there you go, that’s how you turn an impromptu trip to Subway into an analysis of a human-machine systems failure.

 

how to make a load of washing highly socio-technical.

One awkward fact of uni life is that you start reading whatever you’re studying into real life. When I studied Psych, I had fun with using classical conditioning to train my puppy dog. I started studying Anatomy and Physiology, and skin was no longer skin- it was stratified squamous epithelia. Similarly, I just went to put on a load of washing, and the chore of washing clothes had suddenly transformed into a Human-Machine System, or more accurately a mechanical human-machine system.

is it a box? is it a machine? it’s a human-machine system!

The parts in this system consist of:

• the washing machine
• the connection to electricity and water which therefore provide the power to clean my jeans
• the detergent which the human administers
• and me! The human who manipulates control devices to make the complex machine do what I want.

The system goal would be to make my uniforms (and other clothes) not dirty anymore… self-explanatory, right? Additionally, it sings a little tune when it’s done. I’m not sure what relevance that has socio-technically, but I like it. Reward for the user, maybe?
There are PLENTY of Human Factors issues that potentially exist with a washing machine. Just ask any teenage boy- they all seem to have had their socks washed pink at some point.

• putting the wrong colours or new clothes in together (think pink!)
• forgetting to put the lid down on the top (in which case it goes so far and no further)
• forgetting to put powder or detergent in (clothes now wet and smelly..)
• using the wrong settings for the clothes (damage, shrink, run… it’s all possible.)
• I’ve often confused the on/off button with the start/stop button, in which case you have to do all the custom settings again.
• the list goes on.

I can also think of a few notable potential relationship mismatches. For instance, the controls are all in English with no other indication (pictorial, shape, colour) as to what they might do. We often have Asian homestays in the house, so they struggle to use it and often just resort to hand washing. Since it’s a top-loading machine, particularly small people have problems with getting things out, even if they can put them in.

They’ve done fairly well with most other design features, though. For example, the little tune that plays at the end is about 20 seconds long, and it goes through a range of little beeping notes in a cheerful song that cuts through most ambient noise or hearing loss. It’s almost a pity- no more excuses for not hearing that the washing was done.

Now if you’ll excuse me… I have a load of washing to hang up.

sinking and swimming.

Voice comes on over radio in a coastguard office: “Hello, is anyone there? Mayday! Mayday! We are sinking! Repeat, we are sinking!”

The reply: “Hello, zis is the German coastguard…. Vot are you sinking about?’

Old, I know, but good. This is what uni can feel like- I’m almost sinking under the weight of everything to DO (hours of lectures, study, Moodle activities, assignments… etc) and yet, still expected to be thinking coherently. That said, this is proving to be a downright AWESOME term, despite the late start due to being in Sydney.

Obviously, I’ve decided to resurrect the blog (does that make it a zombie blog?), although it’s not required for assessment anymore. It conveniently allows me to keep everyone updated on what I’m up to, if they really want to know. Besides, stalkers are always welcome here- we don’t judge.

So this term I’ve got:

Introductory Anatomy and Physiology (content heavy- but oh so cool! I hope the res school doesn’t involve dead bodies.)

Socio-technical systems (still a little lost with this one, but it’ll all come clear I’m sure. The AINV courses are always fun!)

Introduction to Investigative Methods (the one I’m most behind on but want to be most ahead in… If I wasn’t doing this, I’d be so jealous of people who were.)

Stay tuned for updates on my world, strange tidbits from my studies and odd stories of uni life! And in conclusion, if you feel like you’re sinking, remember that sometimes in swimming, your head goes under.

xo

logic!

If you’re anything like me, this word fills you with annoyance. To have to painfully step out what happens in the space of a thought, to reduce into neat sentences your own intuition… it’s just not fun.

But, it’s something I’ve learned to see the value of- particularly when distinguishing between valid and invalid arguments, and strong or weak arguments. And that judgement depends on whether you can distinguish between a deductive argument or an inductive argument. Confused yet? To explain- with the incident which we’re doing an assignment on (Texas Refinery Explosion- see last post) the day operator’s mental process might have gone a little like this:

Levels in the raffeinate splitter tower under 9 feet are safe.

The level is 8.4 feet and falling.

Therefore, the level is safe.

This is a valid deductive argument: It’s impossible for the premises to be true and the conclusion false. Unfortunately, the premises weren’t true- the measuring gauge that the operator relied on was improperly calibrated. The level of raffeinate in the tower at that time was around 98 feet. And since the conclusion is obviously false (the situation was anything but safe), we know that one of the premises is false.

Inductive reasoning is a little more fuzzy. The night operator, who overfilled the tower as one of the first incidents in the long chain of events, would have thought more along these lines:

We often fill the tower above the gauge level.

This has never caused an accident.

Therefore, overfilling the tower is safe.

For obvious reasons, this is a weak inductive argument. It is entirely possible for the premises to be true and the conclusion false, and there is little other evidence in favour of the conclusion. in fact, in light of the eventual catastrophe, many decisions made leading up to the explosion seem just plain dumb. But somehow, logic was employed (even if it was warped, low-level and invalid)!

If only they’d realised how invalid and weak their logic was overall, some of this might not have happened. So do yourself and others around you a favour today, try and think about something logically. You might surprise yourself.