Monday, June 20, 2016

Bad Design Kills...

You might remember my post earlier this year concerning failed Kickstarter projects and bad EHRs. I also noted that even a big company such as Damlier Fiat Chrysler could embrace a really bad design, in this case, the gearshift. I quoted from Fox News at that time:

Electronic gear shifters on some newer Fiat Chrysler SUVs and cars are so confusing that drivers have exited the vehicles with the engines running and while they are still in gear, causing crashes and serious injuries, U.S. safety investigators have determined...

Agency tests found that operating the center console shift lever "is not intuitive and provides poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection," investigators wrote in the documents. They upgraded the probe to an engineering analysis, which is a step closer to a recall. NHTSA will continue to gather information and seek a recall if necessary, a spokesman said...

In the vehicles, drivers pull the shift lever forward or backward to select gears and the shifter doesn't move along a track like in most cars. A light shows which gear is selected, but to get from Drive to Park, drivers must push the lever forward three times. The gearshift does not have notches that match up with the gear you want to shift into, and it moves back to a centered position after the driver picks a gear.

This particular adventure in poor choices has led to a very unfortunate consequence:  It seems likely that the mis-begotten gear-shift on his Jeep Cherokee led to the death of Anton Yelchin, which I talked about yesterday.

Again, from Fox News:

Gear selectors from 2014 Jeep Grand Cherokee (Left) and 2017 Jeep Grand Cherokee (Right) (Jeep)

The Jeep Grand Cherokee involved in the accident that killed 'Star Trek" actor Anton Yelchin in Los Angeles on Sunday was one of 1.1 million Fiat Chrysler vehicles worldwide subject to a recall to address a transmission design flaw that was cited in several similar incidents, though none fatal.

According to police, Yelchin died from blunt force asphyxia when he got out of the vehicle and it rolled down his driveway and pinned him against a brick mailbox and a security fence. His 2015 Grand Cherokee featured an uncommon type of electronic gear selector that works like a self-centering toggle to cycle through the transmission's modes (park, reverse, neutral and drive,) rather than a lever with notches or specific positions for each.

Hundreds of owners filed complaints with the National Highway Traffic Safety Administration that it was confusing to use. Several had exited their vehicles without having engaged Park as intended, leading to rollaway events despite warning lights and sounds designed to prevent this from happening.

In April, Fiat Chrysler reported that there had been 41 injuries related to the problem and issued a recall for 2014-2015 Grand Cherokees with the 8-speed transmission to update their software to give enhanced warnings and prevent the vehicles from moving if a door is opened when it is not in Park. The 2012-2014 Dodge Charger and Chrysler 300 sedans that used the same gear selector were also recalled. Fiat Chrysler now uses a more conventional lever in all three models.

It’s not yet known if Yelchin’s Grand Cherokee had been brought in for the recall service prior to the accident, but the LAPD says it is trying to determine whether or not the car was in Park when the accident occurred. TMZ has reported that the vehicle had not received the update and was in neutral at the time of the accident.

"FCA US extends its most sincere condolences to the family and friends of Mr. Yelchin,” the automaker said in a statement regarding the accident. “The Company is in contact with the authorities and is conducting a thorough investigation. It is premature to speculate on the cause of this tragedy.”

Police do not suspect foul play in the accident, and that toxicology reports could take months to analyze.
Here is a video of the gearshift lever in operation:

And here is the NHTSA summary:  "Drivers erroneously concluding that their vehicle’s transmission is in the PARK position may be struck by the vehicle and injured if they attempt to get out of the vehicle while the engine is running and the parking brake is not engaged."

And here is where Mr. Yelchin died. . . his own driveway:

My regular readers know what's coming. Maybe I don't even need to say it. But of course, I will anyway.

Poor design has the potential to kill. This should be obvious, self-evident, clear as day. Here, a rising star was snuffed because some engineer at Fiat-Chrysler had a cutesy idea about changing a fundamental part of a car that didn't need to be changed. The shifter needs to shift, easily and confidently, and it needs to be clear just what gear has been selected. Bottom line, it has to work, each and every time it is used. Or someone could die.

Software companies take note:  So it is with PACS (and EHR's). Don't let the engineers and software writers go wild. Don't throw in features just because someone on the team thought it might look good. Don't take an approach that gets between the user and his/her task, here, viewing patient images and information. Test your product with real users. Then test it again. And again. And again. Make sure it works in the hands of the drivers, I mean users...

And I must state this in the strongest, most litigiously slimy terms possible: Medical software has just as much potential to kill as does a faulty shift lever. Never forget that. Create the software you want used on your child or your spouse or your parent. Or on a young, rising actor, who should still be with us.


Anonymous said...

Well said!!! I'm appalled by some of the comments on other articles stating its "operator error". Just ONE person dying is too many.

stacey said...

Why make it complicated? Because computer people are the same people that think layers of Byzantine crap is cool. You know....Socially maladjusted, sexually repressed boys, more comfortable with video
game/computer interaction/Instant messages,as a buffer between, rather than direct human interaction/communication, comic book collecting, comic con attending, dungeon and dragon playing,ITHINKRUSHISTHEGREATESTROCKBANDEVER,still living with

their parents at age 30, dweebs with little awareness of the real world.

Sadly, they are driving our culture as well.

And now they are killing us.