This is an Ignite from our DevOps KC Meetup that does a quick run through of the 'New View'. Everyone should check out the resources on the last slide.

1. The ‘New View’ on
Human Error
Dan Barker

2. Old View
Count absence of negatives
Retributive just culture
Blame the individual
Fix the individual

3. Old View
Count absence of negatives
Retributive just culture
Blame the individual
Fix the individual

4. New View
Count capacity for positive action
Restorative just culture
Blame the system
Fix the system

5. New View
Count capacity for positive action
Restorative just culture
Blame the system
Fix the system

6. Incident Benefits?
Old belief
Lower number of incidents = Lower number of fatalities
Reality
Lower number of incidents = Higher number of fatalities

7. Comparison to CD
The underlying principles are similar to those which provide benefits in Continuous
Deployment
The more frequently you do something, the lower the risk
Fail small
Failure builds up in a system in the form of risk

8. Comparison to CD
The underlying principles are similar to those which provide benefits in Continuous
Deployment
The more frequently you do something, the lower the risk
Fail small
Failure builds up in a system in the form of risk

9. Other reasons
Discourage reporting through retribution
Discourage reporting as the culture values no incidents
Failure to learn from failures
Failure to learn from near misses

10. Other reasons
Discourage reporting through retribution
Discourage reporting as the culture values no incidents
Failure to learn from failures
Failure to learn from near misses

11. System focus
Find faults in the system and fix them
Put controls around critical paths and not just policies
A policy means nothing if it isn’t controlled and audited
Assume fault lies within the system first

12. The goal is restoration
Heal the system
Heal the victims
Heal the second victims

13. The goal is restoration
Heal the system
Heal the victims
Heal the second victims

14. Punishment
Malicious intent
Purposeful illegal activity
Examples:
Transferring client data to unsecured areas
Committing fraud

15. Scenario
Network Engineer
Business Unit VP
Critical change needed for application (Yells the VP to the engineer)
Change Freeze
Change made without Change Advisory Board approval
Change causes outage

16. Scenario
Network Engineer
Business Unit VP
Critical change needed for application (Yells the VP to the engineer)
Change Freeze
Change made without Change Advisory Board approval

17. Consequences
Outage caused to multiple applications
Revenue losses
Reputation losses
Network Engineer fired

18. Tertiary Consequences
Low-trust culture
VP continues pressuring engineers to do the wrong thing
System never fixed to prevent rogue changes
Incidents covered up in the future
Opportunity to learn from failure removed

19. What would you do?
Tell me here:
https://medium.com/@barkerd427/new-view-conundrum-cd2b3a5e3f0e

20. Resources
http://sidneydekker.com/
http://sidneydekker.com/just-culture/
http://sidneydekker.com/courses/
https://itunes.apple.com/us/podcast/preaccident-investigation/id962990192?mt=2
http://www.kitchensoap.com/