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posted on 12 August 2016

Looks Can Kill: The Deadly Results Of Flawed Design

Special Report from ProPublica

-- this post authored by Lena Groeger

Earlier this summer, 27-year-old actor Anton Yelchin was crushed to death when his Jeep Grand Cherokee rolled downhill, pinning him against the security gate in front of his Los Angeles home. No one will ever know exactly what happened in the moments before the accident. But we know that his car is one of more than 1.1 million Jeep and Dodge vehicles that are part of a recall by Fiat Chrysler. The problem? Flawed design.

Specifically, it's the unintuitive automatic shifter, which can make drivers think they've put the car in park when they haven't. If a driver were to exit the car with the engine not in park, all 5,000 pounds of the vehicle could roll away, crashing into any objects (or people) in its path.

A traditional automatic shifter (left), compared to the confusing Fiat Chrysler shifter, shown in a model-year 2015 vehicle, implicated in over 100 crashes (right). Chrysler is no longer producing vehicles with this shifter. (Robert Couse-Baker via Flickr, Fiat Chrysler Automobiles.)

Here's the issue. Traditional automatic-transmission shifters slide to a certain position and stay there, giving you tangible and visual clues about what gear the car is in. The "monostable shifter" in some Chrysler cars, on the other hand, moves and then returns to the center position, no matter what gear it's in. Besides some subtle clicks as you switch gears, there is nothing beside the tiny letters on dashboard or on the shifter itself (conveniently located right under your hand) to show you what gear you're in.

That said, if you do try to get out of the car when it's not in park, warning chimes will go off and alert messages appear on the dashboard. According to Chrysler,

"investigation suggested these measures may be insufficient to deter some drivers from exiting their vehicles."

This flawed shifter "is not intuitive and provides poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection," the National Highway Traffic Safety Administration wrote in a report issued earlier this year.

Problems with the shifter have been implicated in over 100 crashes and dozens of serious injuries, including three cases of a fractured pelvis, a ruptured bladder, a fractured kneecap, broken ribs, a broken nose, facial lacerations requiring stitches, sprained knees, severe bruising, and trauma to legs. If the confusing shifter did contribute to Anton Yelchin's fatal accident, it would be the first known death attributed to it. His family has filed suit against Fiat Chrysler, claiming that the vehicle and gear shift were "defective in design" and "dangerous to life and limb."

defective in their design... and dangerous to life and limb (p. 16)

Selected portion of a source document hosted by DocumentCloud

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Victor and Irina Yelchin filed a lawsuit against Fiat Chrysler for the death of their son. Source: The Superior Court of California, County of Los Angeles

In response to an email, the company said that:

it "extends its sympathies to the Yelchin family for their tragic loss. As this matter is in litigation we cannot comment further at this time."

The current recall would not actually change the design of the monostable shifter. It's a software update that will automatically shift the car into park if the driver fails to do so before opening the driver's-side door. It doesn't correct the flawed usability design, but it does put in place a fail-safe to prevent accidents.

Yelchin's death is tragic. But it's not the first time - nor the last - that bad design has proven dangerous to life and limb. Many of these design problems are easily fixed, which can make them all the more maddening.

Take, for example, household cleaner containers that look like fruit juice bottles. I'm not sure who thought it was a good idea to make a concoction of toxic chemicals look like a refreshingly delicious beverage, but they do exist. And sometimes they're even sold side-by-side.

The colorfully packaged multi-purpose cleaner Fabuloso has a record of mistaken identity. In 2006 researchers looked at about four months of data from the Texas Poison Center Network and found 94 cases of people accidentally ingesting the household cleaner.

Fabuloso comes in a multitude of flavors like lavender, passion fruit and citrus. Just don't drink it. (Maqroll via Flickr)

In case you don't believe that anyone would actually drink multipurpose cleaner accidentally, just ask the six long-distance mountain bikers in Norway who drank laundry detergent thinking it was an energy drink and ended up in the hospital.

The makers of Fabuloso, Colgate-Palmolive, did not respond to ProPublica in time for publication.

Other dangerously designed look-alikes include cooking spray that looks like insect repellant or furniture polish, or truck fuel additives that look like energy shots.

The realm of user experience design (or "UX" for short) is riddled with examples of preventable tragedies. UX designer Jonathan Shariat tells the story of a little girl who died after coming into the hospital for chemotherapy. Her cancer had returned, but that's not what killed her. According to Shariat, her nurses were so confused by the complicated interface of the electronic medical chart software that they forgot to give her three days of intravenous fluid before her chemo treatment began. She died of dehydration and the toxic effects of the undiluted drugs.

Confusing user interfaces are accused of playing a role in everything from plane crashes because of a confusing avionics display to the transplanting of infected organs due to badly designed electronic medical records.

Information designer Edward Tufte has long held that badly designed charts contributed to the 1986 Challenger space shuttle explosion. Even NASA agrees with Tufte that bad design (specifically, PowerPoint's bullet-point rich and information-poor style) contributed to the Columbia disaster in 2003. They explained in their accident investigation report that the debris that struck the shuttle was not deemed as much of a risk as it should have been, in part because of complicated slides:

...it is easy to understand how a senior manager might read this PowerPoint slide and not realize that it addresses a life-threatening situation... The Board views the endemic use of PowerPoint briefing slides instead of technical papers as an illustration of the problematic methods of technical communication at NASA.

Here's that PowerPoint slide they mention, with Tufte's analysis:

The problematic PowerPoint slide. (NHTSA)

Design has the power to make our lives better, and in the overwhelming majority of cases, it does. But when it's done badly, it can put our lives in jeopardy. So if you come across a flawed design - confusing software interfaces, an impossible to-understand gear shift, a juice-like bottle of cleaner - say something. Tweet about it. Call the company in charge. The stakes are much too high to ignore the flaws, wherever they appear.

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