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The ‘New View’ on
Human Error
Dan Barker
Old View
Count absence of negatives
Retributive just culture
Blame the individual
Fix the individual
Old View
Count absence of negatives
Retributive just culture
Blame the individual
Fix the individual
New View
Count capacity for positive action
Restorative just culture
Blame the system
Fix the system
New View
Count capacity for positive action
Restorative just culture
Blame the system
Fix the system
Incident Benefits?
Old belief
Lower number of incidents = Lower number of fatalities
Reality
Lower number of incidents = H...
Comparison to CD
The underlying principles are similar to those which provide benefits in Continuous
Deployment
The more f...
Comparison to CD
The underlying principles are similar to those which provide benefits in Continuous
Deployment
The more f...
Other reasons
Discourage reporting through retribution
Discourage reporting as the culture values no incidents
Failure to ...
Other reasons
Discourage reporting through retribution
Discourage reporting as the culture values no incidents
Failure to ...
System focus
Find faults in the system and fix them
Put controls around critical paths and not just policies
A policy mean...
The goal is restoration
Heal the system
Heal the victims
Heal the second victims
The goal is restoration
Heal the system
Heal the victims
Heal the second victims
Punishment
Malicious intent
Purposeful illegal activity
Examples:
Transferring client data to unsecured areas
Committing f...
Scenario
Network Engineer
Business Unit VP
Critical change needed for application (Yells the VP to the engineer)
Change Fr...
Scenario
Network Engineer
Business Unit VP
Critical change needed for application (Yells the VP to the engineer)
Change Fr...
Consequences
Outage caused to multiple applications
Revenue losses
Reputation losses
Network Engineer fired
Tertiary Consequences
Low-trust culture
VP continues pressuring engineers to do the wrong thing
System never fixed to prev...
What would you do?
Tell me here:
https://medium.com/@barkerd427/new-view-conundrum-cd2b3a5e3f0e
Resources
http://sidneydekker.com/
http://sidneydekker.com/just-culture/
http://sidneydekker.com/courses/
https://itunes.a...
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The ‘new view’ on human error

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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.

Published in: Engineering
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The ‘new view’ on human error

  1. 1. The ‘New View’ on Human Error Dan Barker
  2. 2. Old View Count absence of negatives Retributive just culture Blame the individual Fix the individual
  3. 3. Old View Count absence of negatives Retributive just culture Blame the individual Fix the individual
  4. 4. New View Count capacity for positive action Restorative just culture Blame the system Fix the system
  5. 5. New View Count capacity for positive action Restorative just culture Blame the system Fix the system
  6. 6. Incident Benefits? Old belief Lower number of incidents = Lower number of fatalities Reality Lower number of incidents = Higher number of fatalities
  7. 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. 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. 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. 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. 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. 12. The goal is restoration Heal the system Heal the victims Heal the second victims
  13. 13. The goal is restoration Heal the system Heal the victims Heal the second victims
  14. 14. Punishment Malicious intent Purposeful illegal activity Examples: Transferring client data to unsecured areas Committing fraud
  15. 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. 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. 17. Consequences Outage caused to multiple applications Revenue losses Reputation losses Network Engineer fired
  18. 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. 19. What would you do? Tell me here: https://medium.com/@barkerd427/new-view-conundrum-cd2b3a5e3f0e
  20. 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/

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