human factors and postmortems
TRANSCRIPT
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We deploy quite a lot
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MTTR
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MTTR>
MTBF
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realtalk:things break
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New View
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Complex Socio-Technical Systems
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Erkenntnis und Irrtum fließen aus denselben
psychischen Quellen; nur der Erfolg vermag beide
zu scheiden.— Ernst Mach, Erkenntnis und Irrtum (p. 116)
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Things made sense at the time
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People don't come to work to do a bad job
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Nietzschean Anxiety
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So I always get off the hook whatever I do?
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There is a difference between explaining and
excusing human performance.
— Sidney Dekker, The Field Guide to Understanding Human Error (p. 196)
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BlamelessPostmortems
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Open Meeting
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Everybody is Invited
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Whathappened?
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Timeline
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Describe the pastDon't excuse it away
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The Facilitator
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Guide the Discussion
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Look out for indicators of Old View
thinking
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Counterfactuals
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- she should have- if he would have- if they just had
- you failed to
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Biases
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Hindsight BiasConfirmation Bias
Outcome Bias
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there are many more
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Who is in charge?
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Etsy School
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Taught Facilitator Course
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3 x 90 minutes
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Remediation Items
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incorporate learning and takeaway from
the meeting
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turn surprises into known factors
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MORGUE
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https://github.com/etsy/morgue
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Near Miss
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Pre Mortem
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"Hey all, I just ran rm -rf $DIR/ and since the variable was empty
I deleted my whole VM. This would have been bad in
production. Don't do that."
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ArchitectureReviews
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OperabilityReviews
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It is also worth pointing out that the bias towards
investigating failures rather than success itself represents a trade-off.
— Erik Hollnagel, The ETTO Principle: Efficiency-Thoroughness Trade-Off
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Investigate Success
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Why did it work?
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Human Error is where you stopped looking
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peakscale.com/postmortems
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codeascraft.com
etsy.com/codeascraft/talks
etsy.com/careers
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Questions?