The Life-Changing, and Potentially Life-Ending, Consequences of Bad Design
The technologies that we develop and use transform our lives on a daily basis, from making communication easier between one another to giving us the ability to save lives. However, what happens when the technology we have designed and that we rely on every day to make our lives better takes a life? As designers, we aim to create products that are aesthetically pleasing and function as intended. Nevertheless, many designs seem to neglect the functionality and focus on the aesthetics. This essay will explain how powerful design is, and how we as designers have a certain degree of responsibility to ensure that functionality is made the priority in the design process.
Life-changing and lifesaving, technologies are relied on by millions of people every day. However, the same technologies can result in life-threatening implications if they have not been designed with their intended user at the centre of the design process. I want to delve into how various designs have failed to serve their purpose, as well as the consequences of these failures. I want to demonstrate on how a properly thought out design that functions at a high level is pivotal to ensuring a safe, usable design, and how as designers we should strive to prioritise functionality first, and aesthetics after.
On 20th January 1992, a tragic incident happened due to a thoughtless design that took the lives of eighty-seven people. Two skilled pilots with over 12,000 hours of flying experience between them were travelling to Strasbourg, Germany when adverse weather conditions caused interruptions with the flight’s scheduled course. With their joint experience they calculated that a descent of 3.3 degrees would safely align them with the runway. Unfortunately once the clouds broke the pilots came face-to-face with a mountain and seconds later the horrific collision occurred, only nine people survived. An investigation into how this accident occurred showed that the interface the pilots used to enter information was to blame. The reason that it was difficult to grasp what data was being entered was due to the same screen handled two pieces of key information — Flight Path Angle (FPA) and Vertical Speed (VS). Rather than enter -3.3 for the Flight Path Angle the pilot entered -3,300ft/min for the Vertical Speed. The small interface and the only difference being a missing decimal point robbed people of their lives. This could have easily have been avoided if the interface was more carefully considered. When we design it is vital to understand that unclear information can lead to catastrophic incidents.
Throughout this essay, I will explore how illogical designs have resulted in a number of life-threatening issues and investigate the devastation surrounding the failures of designs that are not intuitive. I will explain how we as designers can end up producing something unusable in conjunction with how shortcuts taken during user testing in the overall design process can result in the loss of life. I believe that if we as designers can understand how these failures happened we could prevent serious incidents from reoccurring in the future, we have the ability to improve — as well as save — lives through our designs.
Every designer is capable of making wrong decisions that result in an unusable design. However, do we neglect to understand the true consequences of creating a design that is not fit for purpose? In this section I will investigate the lack of end-user involvement throughout the design process, and when we neglect the importance to implement usability and design principles in the early stages of a design how it can result in detrimental implications.
Throughout my research I discovered most issues stemmed from the same problem, lack of end-user knowledge and involvement. Systems seemed easy to use, this was due to the people creating them understanding how they worked. However, this created the assumption that the end-user would also be able to navigate the system with ease, although this was not the case. ‘Tragic Design’ by Jonathan Shariat and Cynthia Saucier explains, “Bad designs are the ones that collide with human behaviours and cause undesired friction”. A design built without the end-user in mind has been designed to fail.
Designers have a responsibility to make sure that what they are working on functions properly, as well as being usable. Often as we are working on a design we begin to focus on the appearance and implement designs that are aesthetically appealing, therefore neglecting the fact that they may not be functional for the end-user. Throughout my research I encountered the impact of designs that are unfit for purpose and how it resulted in end-users facing problems that the designer never anticipated.
As stated in Tragic Design, “Badly designed products serve their creator (or sponsor) first and the users second”. As designers we need to focus on designing for a user rather than designing for ourselves, or for a sponsor that may not understand the users needs and focus more on what they feel is important. Often when an employer, or sponsor, wants a design to look and function a certain way we may feel obligated to follow their requests, even though it may not be suited to the end-user. As designers we have a level of responsibility to explain the importance of end-user involvement and clarify how a design must be built around the users needs, and not around personal wishes.
‘Don’t Make Me Think’ by Steve Krug, looks into how the end-user actually uses a website and the various things that we need to consider whilst we are designing. It explains the importance of designing in such a way that the end-user finds a system intuitive and can work everything without being confused or mislead by the interface. Krug explains that “Using a site that doesn’t make us think about unimportant things feels effortless, whereas puzzling over things that don’t matter to us tends to sap our energy and enthusiasm — and time”. This book gave me a clear understanding of how we need to design so that interfaces are self-explanatory, therefore allowing users to figure out how things work without causing them frustration. The more we understand a user and how they actually use what we are designing, then the higher the likelihood that we will design something that they can use with ease.
An example of how we can cause confusion with an interface is the interaction between a user and an online form. Often features are added that make labels disappear when a user begins to type in the field. This feature may look appealing, however, it is problematic for the user. When we add these features we are forcing the end-user to remember what information they have filled in, which can cause frustration. It is important that when we design we make things clear and concise.
Bad design occurs when we do not have a clear idea of who the end-user is. The most important factor that you need to address is the assumption that an average user is a myth; every product has a specific target audience that you need to focus on throughout all aspects of developing a design. Involving the right users is critical for the success of a design, therefore it is vital that you design for the correct audience and get a solid understanding of what they require from a system and the various things that they find vital.
To prevent a design not being suitable, we need to establish early on who the end-user will be and understand what they require from a product. A good way of understanding the users that you are designing for is by creating user personas based on research into a target audience. A user persona gives an overview of what the users needs are stating various information such as goals, frustrations and may also include information on their technical ability. If we have a clear idea of who the end-users are then we can put them at the forefront of every aspect of the design.
Another benefit of creating a persona of users is that it makes us see them as real people. When we dehumanise the end-user then we neglect to understand how a design can truly impact them, or the people around them. Tragic Design explains that when we disconnect from the end-user we are prevented from feeling the shame and guilt associated with the end-user being hurt due to something that we have created. It is important to understand an end-user and have a connection with them and their needs. By truly understanding the user we connect on a more personal level and design with them at the centre of every decision we make, therefore we create something that fits their needs and requirements. As we design we constantly need to think about the user and refer to the issues that they have and aim to fix their problems and improve their lives. Often we forget that there is sometimes far more at risk than a product not selling, we risk taking a life.
If we neglect to involve and consider the end-user throughout the design process then we as designers need to accept that the reason it has failed — or is failing — may be due to our own mistake of not prioritising end-user involvement. It is common to place the blame on the end-user by claiming that are incapable of using a system. There are various sayings, and acronyms that place the blame on the user such as PEBKAC, “Problem Exists Between Keyboard and Chair”. When we neglect to design around the end-user and then proceed to blame them for being unable to use a system then we are not claiming responsibility for how we failed in the design process. The end-user is incompetent of using a system that has not been designed with usability in mind.
When we design with the end-user at the forefront of all our decisions we design a product that is tailored to their needs. We understand that it is our role as designers to create something that is usable, functional and finally aesthetically pleasing. It is common that user involvement can be seen as an expensive cost, although it is important to remember that, as stated in ‘Tragic Design’, “Every dollar spent on user experience brings up to $100 in return”. The satisfaction of the end-user is vital in the success of a product, we are designing and developing something for people to use to improve their lives, and therefore they should constantly be the main priority in all decisions that are made.
Design can have an emotional impact on the end-user, be it happy, sad, frustrated or excluded. I explored why designs have an effect on us emotionally and to gain more knowledge and understanding as to what generates these feelings. Technology has become a normal part of our day-to-day lives and we often rely on it for even the simplest of tasks. We expect technology to have a positive impact, however, when a design causes our lives to become more difficult rather than simpler, then we can become frustrated. When we design we should use the best possible method to ensure the end-user has a positive interaction with the design.
We use social media to share memories with our friends and family that we can look back on and enjoy. However, what if a memory that at one point made us happy now impacts us in a negative way and provides a reminder of sadness rather than happiness? Facebook added a feature that shares various memories, such as pictures, that we previously uploaded or shared on the social media platform. Although this feature has its benefits it is important to consider the emotional impact that something may have on us.
Eric Meyer wrote a blog post, Inadvertent Algorithmic Cruelty, that explains how in 2014, Facebook introduced a feature ‘Year in Review’ that creates a video of all your most liked photos, videos, and statuses from the past year. This feature offered the chance for people to re-live happy memories, however, for Eric this was not the case. Unfortunately, in 2014 his daughter, Rebecca, passed away and upon opening Facebook the first thing he was presented with was an image of his deceased daughter surrounded by illustrations of balloons and people dancing in celebration. Eric had not chosen to create this video, it was automatically generated and shown without his consent, and even more frustrating it was not displayed clearly how to dismiss or hide this feature.
It is important that we understand although features may seem harmless and a nice gesture this isn’t always the case. If you are adding a feature ensure that there is a clear way to remove or dismiss it. This is a small option to add that can have an enormous impact on the end-user.
When designing it is important to consider the limitations that an end-user may have, and the ways in which we can help people by ensuring that our designs are accessible. When a design excludes people they can feel frustrated and unconsidered. However, when we design with accessibility in mind we make sure that any user with a disability does not feel deprived of their independence. According to ‘Tragic Design’, 19% of the population has a disability and as designers it is our responsibility to consider disabilities and enable our software to be accessible to as many people as possible. Some designers feel that if we design for accessibility then we compromise the aesthetics. However, if we design for functionality in all aspects then we can produce something that is useful for the majority of people, rather than something that excludes a group of users and has nice aesthetics.
Ensuring that accessibility is prioritised allows us to positively impact people’s lives and encourages us to move forward in enabling those with a disability to get the most out of technology. Furthermore, if you do not consider accessibility then it is possible that you could potentially be sued for discrimination. ‘Don’t Make Me Think” explains that “Blind people with access to a computer can now read the daily newspaper on their own”. We can take for granted everything we are capable of and forget that others are not as fortunate. As designers we have the ability to dramatically change someone’s life by making relatively minor alterations to our designs. Alternative text, contrasting colours and adding descriptions to hyperlinks are minor considerations that instantly improves how a user with a disability interacts with technology.
If you create a design that negatively impacts a user without intention, then you have failed to understand the user. However, some systems are designed with dark patterns that intentionally cause confusion, and trick the end user into doing something that they have not intended to do.
There are numerous types of dark patterns, one of which is called ‘Bait and Switch’. This is when a user clicks a button expecting a desired outcome, although the result is not what they had intended. Microsoft caused outrage with the Windows 10 upgrade giving the user two buttons, ‘Upgrade now’ or ‘Upgrade tonight’ the only other option was the close button. The issue with this was that the close button did not close the pop-up; instead it automatically started to download the upgrade. This outcome was not expected from the close button resulting in frustration and anger from users and has went as far as resulting in legal action against their invasive upgrade practices.
Another example is the ‘Roach Model’, which works by pre-selecting additional purchases, or a monthly subscription, which you may not realise has been added until you have already paid for it. An example of this would be having a checkbox pre-selected for additional services, such as legal cover by an insurance company. Another way that this works is by making the end-user select the checkbox if they do not want the service. We commonly select a checkbox to say yes to something, therefore when it has to be selected for say no we have been misled.
Alongside checkboxes, you can be met with ‘Trick Questions’ that mislead you into selecting an option that you may not have intended to select. This happens when you glance at the question and think that it has asked one thing, although, once you read it carefully you notice that the question they have asked is something entirely different. An example of this is being presented with the option to opt out of being contacted with various checkboxes for by text, by post or by email. That question naturally feels like it is asking you ways that you would like to be contacted, therefore deceiving the end-user. This particular dark pattern works as according to the Nielsen Norman Group we only read 20% of the text on a webpage, therefore we do not pick up on misleading questions.
Companies have the motivation to use dark patterns to aid their growth and sales, meaning that the end-user suffers at the hands of bad business tactics. ‘Forced Continuity’ is a tactic when you take out a free trial and are required to enter your credit or debit card details to get access to a trail. Once your trial expires you are not given any notice or reminders before your card has been charged for a service that you never intended to sign up for. An example of this is Netflix offering a free month that is advertised clearly at the top of a form, which also requests that you enter your card or PayPal details. The small print along the bottom states that if you do not cancel within the one-month free trial you will automatically be charged for the service. You are being provided with the information that you will be charged for the account, however, you are not sent a reminder that you are going to be charged for the account. This results in many people forgetting that they have signed up and being charged for a service that they may not want.
Although you are being provided with information that you are going to be charged for a service it is important that you remind the end-user that their free trial is coming to an end and they will be charged for the service once the trial expires. Forced continuity works as many of us can easily forget that we signed up for a free trial. By the time we realise we have already been charged for maybe several months for the service.
Dark patterns result in the end user having a negative association with a company, alongside being frustrated due to being misled deliberately. Although profit was made through misdirection, ultimately you will lose customer’s trust resulting in a loss in the long-term. We should never attempt to deceive a user into a product or service as a business tactic. It is important that you give customers clear information and do not deceive them in a bid to make money. Customer satisfaction and a positive relationship with a company will be more beneficial in the long run. Dark patterns trick people into behaving the way that a company desires through deceptive tactics. Good user experiences allow customers to use a company because they offer them a good experience and a positive association with that company.
When we design a system or a product that is meant to help people, we believe that our work is having a positive impact. However, what happens when a design is the reason that someone loses his or her life? I began to research the various times that unusable design has resulted in fatal consequences, and how as designers we have a level of responsibility to ensure that our end-users are kept safe.
The first chapter of ‘Tragic Design’ explains how a user interface resulted in a young girl, Jenny, dying from toxicity and dehydration. This devastating story explains the true impact of bad design and how it can have deadly implications. This dreadful incident happened when nurses trying to use the new system were faced with information overload, causing confusion. The most important information was concealed making it difficult to find, therefore the correct course of treatment was not given to Jenny, resulting in her death.
When we design an interface we can be tasked with placing a vast amount of information on a small device or screen. It is important that as designers we understand the information that should be prioritised, and display this information in such a way it is easily accessed and seen clearly by the end-user. Jenny lost her life due to this very reason. The life-saving information was not easy to see, resulting in it being unnoticed. This resulted in her not receiving the essential care she needed and she sadly lost her life.
The hospital staff had been supplied with a system that displayed a vast amount of information, making it overwhelming and difficult to navigate. The alerts were not clear to see, and attention was not drawn to them meaning that life-saving opportunities were missed. One of the key takeaways of this chapter in ‘Tragic Design’ states a “good visual design reduces the cognitive load required to complete a task”. It is clear looking at the interface that if more attention and thought had been put into the design, and emphasis placed on particular areas of the interface, then maybe a life would have been saved.
Jenny’s death is not an isolated incident as medical technologies have experienced various failures that have resulted in the unfortunate deaths of patients. The Therac-25 is a radiotherapy machine that works by delivering safe doses through an electron, or x-ray, beam. This technology is used during cancer treatments, or to kill malignant cells. This machine was designed to save lives, however, between 1985 and 1987 six incidents occurred resulting in substantial overdoses being given to patients. As a result of these incidents, three patients died due to their injuries and others were seriously harmed.
The Therac-25 worked by the operator entering the prescribed dose and the mode to be administered by the machine. However, the incidents occurred when the machine would blast the patient with drastically more rad, radiation Absorbed Dose, than required. The dose surpassed 17,000 rad when the normal dose was merely 200. This resulted in excruciating pain for the patient. It was that severe that one patient leapt from the operating table and ran to the exit of the room. Even more alarming is the fact that 1,000 rad over a person’s entire body is deemed fatal; therefore the impact of a staggering 17,000 in an area as small as a penny has devastating implications. Burn marks and rashes appeared on the patient’s body within 24 hours of the incident, and over a few weeks, the wound would gradually get worse, developing into a large hole that resembled a gunshot wound.
There are numerous issues that contributed to the failure of Thermac-25, and the interface design played a role in these failings. The interface worked on a command line structure which was controlled using the arrows on the keyboard, rather than a mouse. The first step for the operator was to input the mode, which could have been either “e” for electron or “x” for x-ray, then the operator moved onto the next field. The issue occurred when the operator then realised that they had entered the wrong mode and needed to change it, resulting in them pressing the up arrow on the keyboard. However, the up arrow did not move back to the previous fields, instead, it entered the string of characters that represented the up arrow. The interface had a major failing by not communicating with the end-user about what was going on, and not clearly displaying the field they are typing into and what exactly they are typing.
The lack of end-user feedback caused uncertainty when an error message was displayed that stated; “Malfunction 54” which is not enough information for the operator to know what the problem was. Error messages could be overwritten by pressing the “p” key, therefore meaning that errors were simply suppressed and as a result, a deadly dose of 15,000- 16,000 rad was given to the patient. A few weeks after this incident occurred the patient returned the hospital spitting blood and was diagnosed with radiation exposure. This resulted in his left arm, legs, vocal cords and diaphragm being paralyzed. Five months later he died. This incident was easily avoidable if the end-user had been provided with error messages that explained the problem. Providing them with immediate feedback that highlighted the error would have meant that they may not have dismissed the message without question. There would have been the opportunity to be aware of the situation and to have taken the appropriate action to address the problem.
One of the most alarming issues with the way the Thermac-25 was designed is that it automatically inserted default values. This may be acceptable in some cases to prevent the likelihood of errors, however, dealing with people’s lives and a machine that is administering radiation is not a time when a default value should be used. To make the situation even more frightening the default values were not displayed for the operator to see making this feature a disaster waiting to happen.
The numerous and catastrophic incidents that occurred surrounding the Thermac-25 could have been avoided if more resources were put into user testing. The importance of end-user testing allows you to understand the issues that people are experiencing with the technologies and prevent them from having disastrous effects. Shariat explains, “When it comes to medical interfaces, testing with real users in realistic scenarios is not optional”. User testing could have brought issues to light and inevitably saved lives in the process.
As designers, we need to understand that we have a role to play in safeguarding people that rely on our designs. We need to recognise that a bad design can be dangerous and do everything we can to prevent our work putting someone’s life in danger. As designers, we can often neglect functionality and focus on the aesthetics resulting in a design that is unusable, and not functional. Emphasis needs to be placed on the importance of designing an interface that works and works to a high level. Once a functional design is in place, you can then focus on the aesthetics. When we design something that functions, then we design something that has a purpose. In the case of the interface that killed Jenny the alerts had of been clearer, and the interface less crowded then a death could have been avoided. The devastation around the Thermac-25 could have been prevented if the interface had given adequate feedback to the operator and did not set default values. Minor changes in the designs could have prevented needless deaths.
Throughout my research I developed a solid understanding of the various things that as designers we do that can cause heartache, frustration and fatalities for the people impacted by the systems we design. We are designing technologies with the ability to save lives, or change lives, yet we often forget the importance of usability and instead favouring the aesthetics. We need to design with a solid understanding of what the end-user needs to ensure that our designs function correctly and are usable. An unusable design can result in an innocent life being robbed from someone; therefore we need to see our end-users as real people and understand the devastation surrounding a system that is not fit for purpose.
When we communicate with the end-user and understand what they need and what information is important for them to carry out what they need to do, then we design a system that is functional. The basis of everything we design is to make people’s lives easier, therefore we need to understand the people, and provide them with a system that they can use. We should value their input and design around the user, not for ourselves. A usable system has a much greater value than a visually appealing design with limited functionality.
We have the responsibility to not to cause people distress or frustration through our designs, therefore we should be clear with our communication and ensure that the end-user understands every aspect of various processes by providing strong, clear feedback. We should never intentionally cause the end-user confusion or mislead them to make decisions to try and generate sales. We need to deter people’s desire to add in dark patterns in an attempt to force the end-user to agree, or purchase something that they do not want, or need. Instead, we need to educate and explain the benefits of prioritising a good user experience and how the benefits will be more profitable in the long run.
The ability to change lives, and positively impact people’s lives comes down to considering users feelings, as well as their limitations. A disability does not mean that you should not be considered and does not mean that should be treated in a different way to those around you. Adding in features that make it easier for people with various limitations to use technology and have independence is revolutionary. We need to consider and value every user, as every user is important.
Our design choices offer far more than an appealing interface, they save lives. They give the end-user the tools to complete tasks, to operate life-changing technologies and to be able to use the systems intuitively. We make processes simpler and user-friendly. We give people the ability to use technology and not let a disability restrict their ability to access information. When we design a system that works, we change lives. It is important to understand the importance of design and how every choice that we make throughout the design process can have a positive impact on users.
This was written for part of a university project. You can view the submission website, as well as the credits for imagery & bibliography at www.essay.amber-mcgregor.co.uk. Thank you for reading!
The Life-Changing, and Potentially Life-Ending, Consequences of Bad Design
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