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1鐃
Organizational Learning
When Things Go Wrong
Matthew Graham
@lapsu #SHV16
BS CompEng 2000
http://www.etsy.com
SILICON HAPPY VALLEY 2016
2鐃
Pilot
Operator
Human Error
3鐃
4鐃
5鐃
Old View vs. New View
TAKEAWAYS
6鐃
Old View vs. New View
TAKEAWAYS
Drawbacks
Symptoms
7鐃
Old View vs. New View
TAKEAWAYS
Drawbacks
Symptoms
Approaches
Benefits
8鐃
Organizational Learning
Healthy Culture
Path to Resilience
NEW VIEW BENEFITS
9鐃
SECTION 1
Old View vs. New View
10鐃
What is Human 掘姻姻看姻?
Why do humans make errors?
What to do when errors are made?
11鐃
What is Human 掘姻姻看姻?
12鐃
OLD VIEW
Systems are Reliable
People are Unreliable
14鐃14鐃
15鐃
Human Error
is a Symptom
NEW VIEW
16鐃16鐃
Dead BatteryDead Battery
17鐃17鐃
Indicator BellIndicator Bell
18鐃18鐃
Auto OfAuto Of
19鐃
Why do humans make errors?
20鐃
OLD VIEW
Because They're
Bad Humans
21鐃21鐃
What did they do wrong?
22鐃22鐃
A Bad Apple
at Work
A Bad Apple
at Work
23鐃
People Want
To Succeed
NEW VIEW
24鐃
People Have Reasons:
Tools, Tasks, Situation
NEW VIEW
25鐃
What was the reason
for taking that action?
NEW VIEW
26鐃
What to do when errors are made?
27鐃
OLD VIEW: WHAT TO DO WHEN ERRORS ARE MADE?
Mistakes Have
Consequences
28鐃
Errors Are
Opportunity
NEW VIEW: WHAT TO DO WHEN ERRORS ARE MADE?
29鐃
SECTION 2
Analyzing Failure
1) Identify Symptoms of Old View
2) Replace with New View Approaches
30鐃
SYMPTOM OF OLD VIEW
Retrospection
31鐃
See Sequence of Events in Reverse
Discount Other Possible Outcome
Perspective of Many Individuals
Knowledge of Outcome
RETROSPECTION
32鐃
OUTCOME BIAS
Judging actions more harshly
once the outcome is known
33鐃33鐃
A Pitcher
Catching
Fly Balls?
A Pitcher
Catching
Fly Balls?
34鐃
HINDSIGHT BIAS
Judge a past outcome as
predictable/knowable/obvious
36鐃36鐃
ForesightForesight
36鐃
HindsightHindsight
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Hindsight Foresight
38鐃
Review Events in Order
Available Info Only
NEW VIEW: RETROSPECTION
39鐃39鐃
39鐃
Too Close to the IslandToo Close to the Island
40鐃
Schettino told the trial that it was common for
captains to take their ships close to islands in
order to provide a spectacle for passengers.
- The Telegraph
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Make Sure
Nothing Bad
Happens Ever
Make Sure
Nothing Bad
Happens Ever
Make $Make $
NEW VIEW: BALANCING BUSINESS PRIORITIES
43鐃43鐃
Meeting
Deadlines?
Meeting
Deadlines?
44鐃44鐃
Upon
Failure?
Upon
Failure?
45鐃
Procedures Practice
NEW VIEW: PROCEDURAL ADAPTATIONS
46鐃
'Embarrassing human error'
knocks out Telstra mobile data
and calls nation-wide
CNET HEADLINE 2016-02-16
48鐃
OLD VIEW: BLAME
"We took that node down, unfortunately the
individual that was managing that issue did not
follow the correct procedure, and he
reconnected the customers to the
malfunctioning node, rather than transferring
them to the nine other redundant nodes that
he should have transferred people to."
49鐃
Why didn't individual follow procedure?
Does anyone ever follow procedure?
Did individual know of procedure?
NEW VIEW
50鐃
COUNTERFACTUALS AKA
Shoulda
Coulda
Woulda
51鐃
SUBJUNCTIVE
Subjunctive forms of verbs are typically used to
express various states of unreality
52鐃
OLD VIEW: COUNTERFACTUALS
"We took that node down, unfortunately the
individual that was managing that issue did not
follow the correct procedure, and he
reconnected the customers to the
malfunctioning node, rather than transferring
them to the nine other redundant nodes that
he should have transferred people to."
53鐃
Whatever happened
is what happened
NEW VIEW
54鐃
Why is that what happened?
NEW VIEW
56鐃
Assume Good Intentions
Look to Individual for Info
Look to System for Problems
NEW VIEW: TELSTRA
57鐃
Recovery took 3 hours;
what caused delays?
NEW VIEW: TELSTRA
58鐃
OLD VIEW: BAD APPLE SOLUTION
"While this work is under way, Telstra
Operations has a heightened awareness plan,
including executive-level review of any
changes planned for our mobile and core IP
networks. - Telstra COO
61鐃
SECTION 3
Response to Error
62鐃
SYMPTOM OF OLD VIEW
Justice
64鐃
OLD VIEW: PUNSHMENT
Stop Hearing
About Errors
65鐃
Punishment XOR Learning
66鐃
Learning and Resilience:
New View Benefits
NEW VIEW: RESPONSE
67鐃67鐃
Share Failure Experience
Leadership Too
68鐃
Individual Errs
Organization Learns
NEW VIEW: LEARNING
69鐃
Errors identified sooner?
Faster recovery?
System provide correct action?
Redundancy?
NEW VIEW: RESILIENCE
70鐃
Less Process & Approval
Work Without Obstruction
TRUST IN SUCCESS CONTEXT
71鐃
SUMMARY
Identify Symptoms of Old View
Apply New View Approaches
Learn as an Organization
Improve Resilience
72鐃72鐃
References
The Field Guide to Understanding 'Human Error', Sidney Dekker
http://samnewman.io/blog/2016/02/10/telstra_outage/
http://www.telegraph.co.uk/news/worldnews/europe/italy/11267617/C
osta-Concordia-captain-saluted-Giglio-to-impress-ships-waiter-ex-
captain-and-passengers.html
The Challenger Launch Decision, Diane Vaughan
http://www.cnet.com/au/news/telstra-outage-knocks-out-mobile-
data-and-voice-calls-nationally/
73鐃
Questions?
THANK YOU
Matthew Graham
@lapsu
BS CompEng 2000
http://www.etsy.com

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Organizational Learning When Things Go Wrong