An illustration of many hands, each busy with handling different buttons in a car or plane cockpit
Illustration by Maria Chimishkyan on Mariachimi

Almost every technology, machine, app, website, or software advertises its system as “easy to use”. It is a very common bit of marketing text that is used to help promote, and sell a particular product.

The big question is “easy to use” for whom?

Sure, the system is easy for the developers and business analysts that helped form the design of the system. It might also be “easy to use” for someone with an expert level understanding of the system and experience with the specific application. However, it might be difficult to use for someone without such experience or perhaps when using the application in a specific context of use that does not match the design.

Imagine using a tablet or touchscreen application in an operating room with gloves on. Here, the specific context of use has a huge effect on the overall User Experience. Many injuries and deaths in the healthcare system and aviation are caused by bad usability.

You might wonder how do these even happen? Here is a story of a usability disaster that caused at least 1 death and 38 injuries.

The untested monostable shifter

The Monostable shifter was the reason for a recall in over 1.1 million Fiat Chrysler vehicles in 2016. It was the cause of at least 101 crashes, 38 injuries, and 1 death.

The problem with the monostable shifter was that it had minimal user feedback. With Fiat Chrysler Jeep, it is hard to tell whether someone has put the car into park or not. The difference between reverse and park is incredibly subtle. If a user makes a mistake and opens the door without the car in the park, there is no feedback to let the driver know the car isn’t parked.

Anton Yelchin was famously killed when his Jeep Cherokee pinned him against a wall in his driveway. By the time that had happened, there had been over 250 crashes, and nearly 70 injuries reported due to the monostable shifter.

As noted by David Tracy at Jalopnik, “The mushroom-shaped unit does not slide up and down entirely the way a traditional automatic shifter does, but rather can be moved back or forward while changing gears, after which it then returns to center.”

Tracy quoted the National Highway Traffic Safety Administration:

…operation of the Monostable shifter is not intuitive and provides poor tactile and visual feedback to the driver, increasing the potential for unintended gear selection.

Usability Embarrassment

No product should need a video explaining how to use the basic features of it. Let alone a car…

Some fixes of this issue included warning bells or even automatically parking the car when the door opened. Either way, the drivers were used to operating one way, and this particular vehicle had a different way of doing the same thing.

This was a classic usability anti-pattern derived from cognitive ergonomic: a rote task that users must unlearn.

How could this be avoided with the right research method?

Examples of poorly designed consumer products are legion. The majority of the design failures in the automotive and healthcare industries are typical usability issues that we have already discovered for a few decades.

Illustration of a knife and a blue background screen. The knife is being thrown to the left side of the screen.
Illustration by Al Boardman on giphy
Usability is often a matter of life or death. — Jakob Nielsen

Lack of research or researching by the wrong methodology is the reason behind the inferior User Experience. Running “reliability” and “usability” surveys, rarely help with finding usability issues, not even after mass production and sales.
Instead, standard ergonomics assessment and observation of users can lead to well-documented usability of a product. This way, the business saves itself from bankruptcy and its users from injuries and death.


1. Users are smart people: Users operate in a place where they don’t need to use their smarts to navigate a website. They are focused on a task and don’t even think about the way they do it causing a catastrophic event.
2. User advocacy: When discussing user-experience, I’ve been in scenarios where users don’t come first. I’ve heard folks say “a user can figure it out”, but that’s the sound of an echo-chamber. By advocating the user, you advocate the design and the business.
3. Not valuing user research is costly: Interestingly, this was just one case where these issues were brought to light. Now, I wonder how many businesses are losing revenue each day and if there are other lives at risk too.


Campbell, J. L. (2012). Human factors guidelines for road systems (Vol. 600). Transportation Research Board.

Long, J. (2000, July). Cognitive ergonomics–past, present, future: 10 lessons learned (10 lessons remaining). In Proceedings of the Human Factors and Ergonomics Society Annual Meeting (Vol. 44, №6, pp. 557–560). Sage CA: Los Angeles, CA: SAGE Publications.

Zhu, Y., Rodriguez-Paras, C., Rhee, J., & Mehta, R. K. (2020). Methodological approaches and recommendations for functional near-infrared spectroscopy applications in HF/E research. Human factors, 62(4), 613–642.

More UX reads:

Can You Land a Job in UX Research with Zero Qualifications?

Can you land a job in UX Research with zero qualifications?

Hossein Raspberry is a Usability Engineer and Researcher. He studied Applied Psychology and Human-Computer Interaction. He loves cooking mouth-watering Persian food and writing about topics he cares about in his spare time.

The UX Collective donates US$1 for each article published in our platform. This story contributed to UX Para Minas Pretas (UX For Black Women), a Brazilian organization focused on promoting equity of Black women in the tech industry through initiatives of action, empowerment, and knowledge sharing. Silence against systemic racism is not an option. Build the design community you believe in.