What links the frustrations of daily life, like VCR clocks and voicemail systems, to airplane crashes and a staggering “hidden epidemic” of medical error?

Kim Vicente is a professor of human factors engineering at the University of Toronto and a consultant to NASA, Microsoft, Nortel Networks and many other organizations; he might also be described as a “technological anthropologist.” He spends his time in emergency rooms, airplane cockpits and nuclear power station control rooms -- as well as in kitchens, garages and bathrooms -- observing how people interact with technology.

In the first chapter of The Human Factor, Kim Vicente sets out the disturbing pattern he’s observed: from daily life to life-or-death situations, people are using technology that doesn’ t take the human factor into account. Technologies as diverse as stove tops, hospital work schedules and airline cockpit controls lead to ‘human error’ because they neglect what people are like physically, psychologically, and in more complex ways. The results range from inconvenience to tragic loss of life.

How has this situation come about? The root cause of the problem, Vicente explains in the second chapter, is a “two cultures” issue. There is a divide in the world of technological design -- just as there is in the world more generally -- between humanistic and mechanistic world-views. The humanistic view (in, say, cognitive psychology) deals with people in the abstract, ignoring that using tools is an integral human activity. The mechanistic view, on the other hand, forgets that it is real people who have to use the tools engineers develop. The two groups aren’t talking to each other: as the author puts it, “our traditional ways of thinking have ignored -- and virtually made invisible -- the relationship between people and technology.”

As is often the case in human factors engineering, the solution is both revolutionary and, on the surface, simple: what we have to do is focus on the relationship between people and technology. Taking a cue from systems thinking, Kim Vicente argues that we should focus not just on better products or better practices, but the fit between them. What this means is not the development of more high-tech or low-tech articles, but a Human-tech revolution, where the human comes before the technological but the two are always linked.

In some areas the revolution is already at work: it’s not always the case that technology doesn’t take the human factor into account. When it does, as in the case of the Reach toothbrush, the Palm Pilot, or the “critical incident” reporting method developed at the Philadelphia Children’s hospital, the technology is a success. The Fender stratocaster guitar became the favourite of musicians around the globe because it was designed with the needs of guitarists in mind, in everything from its overall shape to the position of its controls. The Human-tech Aviation Safety Reporting System, a way for pilots to confidentially report near-misses, has made air travel dramatically safer.

Technology as Kim Vicente understands it isn’t just the physical “stuff” we use. In The Human Factor the word is used in a much broader sense, to include the physical and non-physical elements of complex systems. Information, teamwork, organizational structures and political decisions play a crucial role in determining how well a technological system as a whole functions. The “Human-tech ladder” sets this out in more detail, and also provides the structure for the rest of the book. Design should begin by understanding a human or societal need, and then tailoring the technology to reflect what we know about human nature at the physical, psychological, team, organizational and political levels.

Kim Vicente offers a host of examples of technology relating to human needs poorly and well at each level. The physical is perhaps easiest to understand: a toothbrush that fits into hard to reach parts of the human mouth is better tailored to the human body than one that cannot. At the psychological level, technology has to take into account how people process and remember information, whether in designing voicemail systems or airport baggage checks. Poor Human-tech can be devastating. For example, awkwardly placed and uninformative gauges in the design of the control room at the Three Mile Island nuclear power station left even highly trained engineers uncertain as to the status of the reactor, contributing to the infamous accident there.

At the team level, the Cockpit Resource Management system is a way of training pilots to communicate and share responsibilities effectively. The way people work together is itself a form of technology that needs to run smoothly to avoid disastrous accidents, such as the time an Eastern Airlines jet crashed in Florida because the entire crew was distracted by the condition of an unimportant light bulb and no-one attended to flying the plane.

Kim Vicente discusses the human factor at the organizational level in chapter seven of The Human Factor. “Soft” technology such as staffing levels and corporate culture can be designed so that an organization learns from its front-line staff. For instance, the medical community traditionally holds individual doctors and nurses responsible for mistakes. When things go wrong we tend to blame people -- when in fact they may have made heroic efforts to use poorly designed technology. Errors in hospitals are more often the result of systemic flaws: none is wholly at fault, but together they interact to cause accidents. At the Philadelphia Children’s hospital, the Human-tech solution is a system which encourages staff to make full reports on near-misses, and asks them to tell managers about potential dangers so that the hospital as a whole can institute protective measures. This critical incident technique led to a 90% reduction in medical mistakes at the hospital.

The final level of human nature which The Human Factor addresses is the political. Here, a Human-tech shows us that when political elements -- laws, funding, regulations -- ignore what we know about human nature, dangers arise. In the case of the E. coli tragedy in Walkerton, Ontario, Kim Vicente uncovers a host of “system design” elements at the political level -- policy aims, legal regulations, budget allocations -- which interacted with environmental factors and staff incompetence to kill seven people and make thousands of others sick.
In conclusion, Kim Vicente feels that our civilization is at a crossroads: we have to change our relationship with technology to bring an end to technology-induced death and destruction, and start to improve the lives of everyone on the planet. The final chapter of The Human Factor sets out the ways we can regain control of our lives. As consumers, we can recognize and distinguish better designed products, and buy the more Human-tech ones. By participating actively in society we can remind people that ignoring the human factor, as happened at Walkerton, has terrible implications. In our workplaces we can all ensure that more human friendly technologies, hard and soft, predominate. Companies need to take a Human-tech approach to the rules and practices they institute, and design soft systems to guarantee that their employees have the competencies, information, goals and commitment to do their jobs. Other bodies, from the media to engineering schools can all play their part in making technology with a close affinity to human nature the norm rather than a rarity: a better world will be the inevitable result.

Kim Vicente's profile page

• Nominated, Canadian Booksellers Association Libris Award - Non-fiction Book of the Year
• Winner, National Business Book Award

In 1999, KIM VICENTE was chosen by TIME magazine as one of twenty-five Canadians under the age of forty as a “Leader for the 21st Century who will shape Canada’s future.” A professor of engineering at the University of Toronto, he lectures widely around the world and has acted as consultant to, amongst others, NASA, NATO, the US Air Force, the US Navy, Microsoft and Nortel.
He lives in Toronto.

“[Kim Vicente] calls for a revolution in thinking.”
—Winnipeg Free Press

“Refreshingly, The Human Factor is not a techonophile’s rant. [Vicente] takes a considered look at how we can turn around our sometimes frustrating dealings with machines and bureaucracies and use them instead of them using us. And, even more importantly, how we can make all of this safer. Vicente underlines his premise with extraordinary statistics. … [H]e simplifies complex ideas and presents them along with simple diagrams.”
—Christopher Dewdney (poet, author of The Natural History), The Globe and Mail

“Vicente has a wonderful ability to find the perfect example to illustrate each of [the book’s] principles. … Each chapter of this amazing book has its own strenths. … This is no ordinary book; it is a joy to read, instructuve and provocative. Vicente has been hailed as one of the 25 Canadians under 40 who will reshape Canada. Having read The Human Factor, I find that easy to believe.”
—The Edmonton Journal

“By turns enchanting and disturbing, Vicente’s marvellous book is full of advice on how to make this a more elegant, as well as a safer, world.”
—Maclean’s
Advance Praise:
“What form of social change could save lives, boost the economy, and increase health and happiness, all without political wrangling or moralistic finger-pointing? The answer: making our technology work better with human minds and bodies. This delightful and important book explains how we can at last reap the fruits of the recent revolution in technology. It should be required reading for all engineers.” -- Steven Pinker, Johnstone Professor of Psychology, Harvard University, and author of The Blank Slate and How the Mind Works

“This book may well be a landmark in changing our view of technology, and its place in our world. Kim Vicente is a visionary. He understands the value of using technology to help people, rather than technology for the sake of technology. He places human needs and values first. The world today badly needs such people.” -- Alan Lightman, author of Einstein’s Dreams
“Kim Vicente is an engineer who understands how all our lives are being engineered. You will put down this book with a new awareness of the link between devices and those who use them. And you will have been greatly entertained.” -- John Polanyi, Nobel Laureate

“This book saves lives. Strong words? Yes, but this is a strong book: engaging, easy to read, but carrying a powerful message. We have far too long neglected the human and social side of technology. When accidents happen, we rush to find blame, to sue, fire, penalize and otherwise punish people when it is the system that is at fault. The result is needless accidents in vehicles, hospitals, manufacturing plants and, worse, no way of stemming the tide, of learning from our actions and making life better, safer, more enjoyable. The Human Factor can indeed revolutionize the way we live with technology. Read this book: it can save lives.” -- Don Norman, author of The Design of Everyday Things and co-founder of the Nielsen Norman group
"We've all had frustrating experiences with gadgets, devices, and machines that seem to have been designed by idiots. They make our lives more difficult and sometimes even dangerous. The designers weren't really idiots, of course, but they failed because they hadn't taken full account of the physical, psychological, social, and political context in which their designs had to function. Kim Vicente peels away this context like the layers on an onion, and in the process tells the true story of why so many of the technologies critical to our lives fall so short of their potential. He shows us how technologies are far more than mere machines – they are creations of societies as well as scientists and engineers. And he shows us, too, how we all have an urgent responsibility to understand what makes technologies succeed or fail. Moving from toothbrushes to nuclear reactors to the Walkerton water tragedy, The Human Factor is a triumph of investigation, analysis, and marvelous storytelling – a must-read at the dawn of the technology-supercharged 21st century." -- Thomas Homer-Dixon, author of The Ingenuity Gap