When bad design kills

Lena Groeger of ProPublica writes about cases of bad design that can lead to death or other dangerous situations. She starts with the freak accident that killed actor Anton Yelchin.

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.

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.

Some of the other flawed designs fall into the “What the hell were they thinking?” category, especially Fabuloso household cleaner bottles that look like fruit juice bottles, so much so that they are sometimes even sold side by side because the shelves stockers were misled.

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

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

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.

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.

Part of the problem may be the desire of designers to do something distinctive, that stands out from the rest, to attract people’s attention. With rental cars, for instance, sometimes it takes me quite a lot of time to figure out how the controls for the lights, heat/cool, mirrors and seats, work. While most are intuitive, some are not.


  1. jrkrideau says

    Donald A. Norman who studies such things discusses any number of poor design decisions http://www.jnd.org/books.html.
    It’s amazing how many ways one can muck up, I loved the story of the German bank where people got trapped between the doors and could not escape.

  2. says

    With rental cars, for instance, sometimes it takes me quite a lot of time to figure out how the controls for the lights, heat/cool, mirrors and seats, work. While most are intuitive, some are not.

    I stayed in a fancy Swiss hotel (the Widder, FWIW) that had this shower controller that was some fancy piece of stainless steel gadgetry that you pulled and twisted to control the temperature and the amount of water. There was another twisty pull you had to do in order to make the water switch from the tub faucet to the overhead. In the course of all the twisting I turned it to maximum heat and then to full on, and got blasted by water that felt like it was near boiling. Impressive design, really.

  3. Matt G says

    My SO has a Mercedes sport sedan from 2003. The signal indicator lever has five “states” (for lack of a better term). Instead of the usual three (left, right and off), you can move the lever slightly up or down to have the car signal four flashes. The idea is that this is the time it takes to change lanes. Wonderful. The problem is, once the sequence starts, IT DOESN’T STOP! If you change your mind about changing lanes, you have to first signal in the opposite direction to stop it, and then return the lever to the off position. Stupid, and dangerous. Innovation for its own sake, not to make anything better.

  4. jrkrideau says

    @3 Matt G.
    And often the designer has not the slightest clue of what the end user needs.

    In a way it may be a trivial complaint but have you noticed that all (almost all?) bottles of injectable drugs we see when visiting the hospital are small squat brown glass things with some kind of rubber top? Just how easy might it be for a nurse or doctor under stress and time-pressure to get to another urgent case to grab one rather than the other?

    It is a case of shockingly poor design. Heck, my local pub has different bottles/cans/beer handles that reduces the chance of me getting the wrong beer that is better than hospital drug bottles.

    Oh, and to get back to my origin point about the clueless designer, years ago, perhaps in the 1980’s, the City of Toronto built a lovely pedestrian/bicycle bridge over the Don Valley. Soon pedestrians were complaining about speeding cyclists and the designer lamented, “But we expected everyone to stop and enjoy the view”.
    Heck, to a cyclist, it was a prime commuter route and the idiot who probably had never ridden a bike failed to appreciate that he had mixed two groups with diametrically opposed needs.

  5. flex says

    As a long-time automotive engineer, I can say that all the automotive OEMs have HMI (human-machine interface) departments. How much their insight is used can vary among vehicle platforms. Styling decisions can over-ride the HMI requirements, and what is even more unsettling is that a senior VP will review a car and decide that a feature must be changed because they personally don’t like it.

    I’ve worked in automotive interior controls for years, and spent a great deal of time working on HMI proposals. We developed what we thought was a very innovative HVAC/Radio console control where the plastic was molded into features allowing the driver to identify the controls and activate them without looking at them. We were using the same technology as touch-screens, but that technology does not require a screen to use, you can put the touch sensors behind a piece of molded plastic. So we could backlight areas which were necessary, give the driver both visual and tactile information, and we even had tactile feedback that the function was activated by tapping the plastic from behind so that a finger could feel a change.

    It was not considered sexy enough to sell cars. So while the engineering teams at the OEMs loved it, no platform picked it up because it looked too much like the older controls that everyone was familiar with.

  6. Mano Singham says


    Your comment reminds me of a similar situation in a different context. My university went through a long and detailed process involving faculty, staff, and students to develop a five-year plan and produced a report giving our recommendations to the administration. When the university issued the plan, though, there were some major items that we had not even discussed, let alone recommended.

    It turned out that the people involved with marketing the university to the public felt that our plans were not ‘exciting’ enough and simply inserted new items that lacked any rationale.

  7. lorn says

    Not too long ago there was a series of accidents with injectable Heprin. Local hospitals had changed suppliers and the new 25000IU bottles were the same label color, shape, and size as the old 5000IU bottles. Long shifts, and overworked nurses (and absolutely no warning) meant they reached for what looked like exactly same bottle they had been grabbing for over a decade.

    Design matters.

  8. Crimson Clupeidae says

    I wish cars would go the way of aircraft in terms of controls. While the controls exact layout will vary amongst aircraft, the actualy knob on the control is consistent (it’s required by the regulations) and the type of motion required is the same.

    In general most cars are pretty standardized, but there’s enough wierdness that rentals often take 5-10 minutes of familiarization before driving off.

  9. flex says

    @Crimson Clupeidae, #9,

    Actually, a lot of the controls in automobiles are pretty standardized. Largely for safety reasons. There is a set of government standards, Federal Motor Vehicle Safety Standards (FMVSS) which covers required information on the dashboard, what each symbol means, what functions MUST be on the vehicle, etc.

    Many of the requirements are matched by other countries world-wide (actually a lot of them are developed in France and Germany and then adopted by NHTSA).

    One of my favorite symbols is usually unnoticed by drivers. There is a little triangle (or arrow) next to the picture of the Gas Pump near the fuel gauge. That triangle points to the side of the car where the port to fill the gas tank is. It points toward the gas cap, so you know without having to get out of your car which side of the pump you need to pull up to. People may see it, but many have no idea that it is actually conveying useful information. (Note: I just did a quick search, and it apparently has been the topic of a number of blogs, so maybe the knowledge is getting around.)

  10. Chiroptera says

    With rental cars, for instance, sometimes it takes me quite a lot of time to figure out how the controls for the lights, heat/cool, mirrors and seats, work. While most are intuitive, some are not.

    You know, I’m in my 50s, and I have never, in my entire life, ever figured out how to operate the climate control system in a car, even the non electronic ones in the 80s. Whenever a driver asked me in the past to turn up the heat, I just fiddled with knobs and sliders until they got tired of me and reached over to do it themself.

  11. Peter B says

    for flex@5 and somewhat OT

    Free idea: Cabin Air Control

    I mention 3 degrees of freedom: air volume for defrost, face and foot.

    Let’s put one of those degrees of freedom into fan speed. Then using rocker switches or touch controls select the ratio defrost:face:foot. (This is NOT how to explain it to marketing.)

    Think of an equilateral triangle with one point pointing toward the driver. Up on the rocker switch pointing to the driver increases the air to the drivers face, down decreases it. The switch by the top triangle vertex control the defrost air, the lower switch does up/down on the foot air.

    Or do the equivalent with a joy stick. Perhaps add a graphic readout for higher end cars. I would make the default cabin air control mostly face with some foot when cooling and some defrost when heating.

    I want defrost and face only most of the time. I have never seen that option.

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