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Advanced
PostMortem Fu
& Human Error 101

                    John Allspaw
                    VP, Tech Ops
                    Velocity 2011
We Want    YOU
    etsy.com/careers
Science
TimeTravel
Mythbusting
Reading
Homework
Here To Challenge You
Resilience Engineering



Dr. Erik Hollnagel   Dr. David Woods Dr. Sidney Dekker Dr. Richard Cook
Complex, Dynamic
Fundamental Surprises
E.T.T.O.


    Efficiency   Thoroughness
Organizations, Policies, Procedures,
           Regulations
                                       BLUNT
       Resources & Constraints
Organizations, Policies, Procedures,
                  Regulations
                                                    BLUNT
                Resources & Constraints

      Slips                               Adjustments
                    Operators
Compensations                             Mistakes
    Lapses                                Recoveries
 Violations                               Improvisations
                                                    SHARP
FUTURE
  +
PAST
Why Do Them?
Why?

Understand the
                 failure
Why?

Understand the
                 system
Where “System” =
                     Networks
                        Servers
                   Applications
                    Processes
                         People
Where “System” =
                     Networks
                        Servers
                   Applications
                    Processes
                        People
People
(Anticipation)
    Knowing
      What
    To Expect
(Anticipation)
    Knowing         Knowing
      What            What
    To Expect      To Look For

                 (Monitoring)
(Anticipation)                   (Response)
    Knowing         Knowing        Knowing
      What            What          What
    To Expect      To Look For      To Do

                 (Monitoring)
(Anticipation)                   (Response)
    Knowing         Knowing        Knowing      Knowing
      What            What          What          What
    To Expect      To Look For      To Do     Has Happened

                 (Monitoring)                 (Learning)
(Anticipation)                   (Response)
    Knowing         Knowing        Knowing      Knowing
      What            What          What          What
    To Expect      To Look For      To Do     Has Happened

                 (Monitoring)                 (Learning)
Microphones are ON?
Event Awareness



Code Deploys
TIMELINE
      IRC logging = Rich Data
TIMELINE       Traces of Data
      IRC logging = Rich Data
IRC Logs Fed Into Solr
Status
 Blog
Twitter
 Feed
Flight Data Recorder
Annotation Traces
Investigation Basics
Start?
TTD

How?
TTR
Stable
(“all clear”)
Impact Time = TTR - Start
SEVERITY
Severity 1

A. Total loss of service
B. Severe degradation, effectively unusable
C. Loss of a critical feature
Severity 2


A. Major degradation/feature loss for SUBSET of members
B. Minor degradation/feature loss for ALL members
Severity 3


Noticeable non-critical feature loss or degradation
Severity 4

No visible impact, loss of redundancy or capacity
headroom
Severity 5


No-impact but unexpected failure
5/11/2011 - Payments/Checkout system issue

   Start                                     4:10pm
   TTD                                       4:15pm
   TTR                                       4:30pm
   Stable                                    4:35pm
   Total Impact                              20 min
   Severity                                     1
•   Basic metrics
•   Timeline with details
•   Remediations/Observations
“normal”
            Incident   PostMortem
operation




              Time
How?
Why?
Prevention?
How
Crisis Patterns
Problem Starts




                              PostMortem
                 Time
Crisis Patterns
Problem Starts

      Detection




                               PostMortem
                  Time
Crisis Patterns
Problem Starts

      Detection
             Evaluation




                                       PostMortem
                          Time
Crisis Patterns
Problem Starts

      Detection
             Evaluation
                     Response




                                         PostMortem
                           Time
Crisis Patterns
Problem Starts

      Detection
             Evaluation
                     Response
                                Stable




                                         PostMortem
                           Time
Crisis Patterns
Problem Starts

      Detection
             Evaluation
                     Response
                                Stable




                                                       PostMortem
                                         Confirmation

                           Time
Crisis Patterns
Problem Starts

      Detection
             Evaluation
                     Response
                                Stable




                                                                   PostMortem
                                         Confirmation
                                                       All Clear
                           Time
Crisis Patterns
Problem Starts
                          Stress
      Detection
             Evaluation
                     Response
                                Stable




                                                                   PostMortem
                                         Confirmation
                                                       All Clear
                           Time
Crisis Patterns
Problem Starts




                              PostMortem
                 Time
Crisis Patterns
Problem Starts

      Detection




                               PostMortem
                  Time
Crisis Patterns
Problem Starts

      Detection   Evaluation




                               PostMortem
                  Time
Crisis Patterns
Problem Starts

      Detection   Evaluation
                    Response




                               PostMortem
                  Time
Crisis Patterns
Problem Starts

      Detection   Evaluation
                    Response
                          Stable




                                   PostMortem
                  Time
Crisis Patterns
Problem Starts

      Detection   Evaluation
                    Response
                          Stable




                                              PostMortem
                                Confirmation


                  Time
Crisis Patterns
Problem Starts

      Detection   Evaluation
                    Response
                          Stable




                                                  PostMortem
                                Confirmation
                                      All Clear
                  Time
Crisis Patterns
Problem Starts                 Stress
      Detection   Evaluation
                    Response
                          Stable




                                                  PostMortem
                                Confirmation
                                      All Clear
                  Time
Crisis Patterns
Problem Starts




                              PostMortem
                 Time
Crisis Patterns
Problem Starts
      Detection




                               PostMortem
                  Time
Crisis Patterns
Problem Starts
      Detection
          Evaluation




                                    PostMortem
                       Time
Crisis Patterns
Problem Starts
      Detection
          Evaluation
               Response




                                       PostMortem
                          Time
Crisis Patterns
Problem Starts
      Detection
          Evaluation
               Response
                                 Stable




                                          PostMortem
                          Time
Crisis Patterns
Problem Starts
      Detection
          Evaluation
               Response
                                 Stable




                                               PostMortem
                                 Confirmation


                          Time
Crisis Patterns
Problem Starts
      Detection
          Evaluation
               Response
                                 Stable




                                                 PostMortem
                                 Confirmation
                                     All Clear
                          Time
Crisis Patterns
Problem Starts                      Stress
      Detection
          Evaluation
               Response
                                 Stable




                                                 PostMortem
                                 Confirmation
                                     All Clear
                          Time
Problem Starts
      Detection
          Evaluation
               Response
                                 Stable




                                                 PostMortem
                                 Confirmation
                                     All Clear
                          Time
Problem Starts
      Detection
          Evaluation
               Response
                                 Stable




                                                 PostMortem
                                 Confirmation
                                     All Clear
                          Time
Problem Starts
      Detection
          Evaluation
               Response
                                 Stable




                                                 PostMortem
                                 Confirmation
                                     All Clear
                          Time

    Internal and External Update Communications
Crisis Patterns
Problem Starts
      Detection
          Evaluation
               Response
                                 Stable
                                 Confirmation
                                     All Clear
                          Time
Crisis Patterns
Crisis Patterns
Forced beyond learned roles
Crisis Patterns
Forced beyond learned roles
Actions whose consequences are both important and
difficult to see
Crisis Patterns
Forced beyond learned roles
Actions whose consequences are both important and
difficult to see
Cognitively and perceptively noisy
Crisis Patterns
Forced beyond learned roles
Actions whose consequences are both important and
difficult to see
Cognitively and perceptively noisy
Coordinative load increases exponentially
Thematic Vagabonding
“butterfly minds”



       NOT STUCK ENOUGH
Goal Fixation
                 (encystment)



TOO STUCK
Heroism

Non-communicating lone wolf-isms
Distraction

Irrelevant noise in comm channels
IMPROVISATION

REQUIREMENT for troubleshooting
complex systems
IMPROVISATION
IMPROVISATION
Why?
Root Cause Analysis
“With the unknown, one is confronted with danger,
discomfort, and care; the first instinct is to abolish
these painful states.
First principle: any explanation is better than
none.”



                                         Friedrich Nietzsche
                                        Twilight of the Idols, or
                           How to Philosophize with a Hammer
Hindsight Bias
Knowledge of the outcome influences the
analysis of the process


Makes steps towards failure appear
foreseeable and obvious
After The Fact
After The Fact
Reality: Before and During
Hindsight Bias
“Should have known better”


“All the signs were there, you just needed to
pay attention”
Hindsight Bias
BEFORE accident:
        The future seems implausible
AFTER accident:
   Obviously clear: “how could they not see what
   mistake they were about to make”
Hindsight Bias
“...people’s need to be right
is stronger than their ability
to be objective.”
                          N. Crawford
          American Psychological Association
Outcome Bias


Judging a past decision
based on its outcome.
ID          Fishbone/Ishikawa

     FMEA
                         Five Whys
                Fault Tree      CED
      CRT
why?
       OUTAGE
why?
because
  this
             OUTAGE
why? why?
  because
    this
            OUTAGE
why? why?
because   because
  this      this
                    OUTAGE
why?     why? why?
   because   because
     this      this
                       OUTAGE
why?       why? why?
because   because   because
  this      this      this
                              OUTAGE
why?        why? why?
because    because   because
  this       this      this
                               OUTAGE


          but: WHY?
which
                       caused


Some       Caused       other
Action   Some Things   things
                                OUTAGE

                         to
                       happen
Sequence-Of-Events
• Satisfyingly simple, easy to explain and document
•   Satisfyingly simple, easy to explain and document
•   Solves for a specific case
•   Ignorant of surrounding circumstances
•   Too focused on components
•   Validates Hindsight and Outcome bias
NOT HELPFUL
•   Satisfyingly simple, easy to explain and document
•   Solves for a specific case
•   Ignorant of surrounding circumstances
•   Too focused on components
•   Validates Hindsight and Outcome bias
Epidemiological



        (adapted from Reason, 1990)
(adapted from Reason, 1990)
Holes = Active/Latent Failures,
Bad Things™ Waiting to Happen




                  (adapted from Reason, 1990)
Holes = Active/Latent Failures,
                            Bad Things™ Waiting to Happen




Cheese = Safety Barriers,
   Layers of Defense                          (adapted from Reason, 1990)
(adapted from Reason, 1990)
Code   Servers




           (adapted from Reason, 1990)
Code        Servers




Schedule     Training   (adapted from Reason, 1990)
Unmonitored Disk Space
   (latent condition)
Capacity
                     Unmonitored Disk Space
  Miscalculation
                        (latent condition)
(latent condition)
Capacity
                     Unmonitored Disk Space
  Miscalculation
                        (latent condition)
(latent condition)




                               Unit Test In
                               Transition
Violation of known coding
     Capacity                standards         Unmonitored Disk Space
  Miscalculation         (latent condition)       (latent condition)
(latent condition)




                                                        Unit Test In
                                                        Transition
Violation of known coding
     Capacity                          standards         Unmonitored Disk Space
  Miscalculation                   (latent condition)       (latent condition)
(latent condition)




                                                                  Unit Test In
                     Bug Introduced
                                                                  Transition
                     (active failure)
Violation of known coding
     Capacity                          standards         Unmonitored Disk Space
  Miscalculation                   (latent condition)       (latent condition)
(latent condition)




                                                                  Unit Test In
                     Bug Introduced        External API call
                                                                  Transition
                     (active failure)       (active failure)
Violation of known coding
     Capacity                          standards         Unmonitored Disk Space
  Miscalculation                   (latent condition)       (latent condition)
(latent condition)




                                                                  Unit Test In
                     Bug Introduced        External API call
                                                                  Transition
                     (active failure)       (active failure)
Violation of known coding
     Capacity                          standards         Unmonitored Disk Space
  Miscalculation                   (latent condition)       (latent condition)
(latent condition)




                                                                  Unit Test In
                     Bug Introduced        External API call
                                                                  Transition
                     (active failure)       (active failure)
Violation of known coding
     Capacity                          standards         Unmonitored Disk Space
  Miscalculation                   (latent condition)       (latent condition)
(latent condition)




                                                                  Unit Test In
                     Bug Introduced        External API call
                                                                  Transition
                     (active failure)       (active failure)
Violation of known coding
     Capacity                          standards         Unmonitored Disk Space
  Miscalculation                   (latent condition)       (latent condition)
(latent condition)




                                                                  Unit Test In
                     Bug Introduced        External API call
                                                                  Transition
                     (active failure)       (active failure)
Violation of known coding
     Capacity                          standards         Unmonitored Disk Space
  Miscalculation                   (latent condition)       (latent condition)
(latent condition)




                                                                  Unit Test In
                     Bug Introduced        External API call
                                                                  Transition
                     (active failure)       (active failure)
Violation of known coding
     Capacity                          standards         Unmonitored Disk Space
  Miscalculation                   (latent condition)       (latent condition)
(latent condition)




                                                                  Unit Test In
                     Bug Introduced        External API call
                                                                  Transition
                     (active failure)       (active failure)
Violation of known coding
     Capacity                          standards         Unmonitored Disk Space
  Miscalculation                   (latent condition)       (latent condition)
(latent condition)




                                                                  Unit Test In
                     Bug Introduced        External API call
                                                                  Transition
                     (active failure)       (active failure)
                                                               FAILURE!
Capacity
  Miscalculation
(latent condition)




                                                            Unit Test In
                     Bug Introduced     External API call
                                                            Transition
                     (active failure)    (active failure)
Capacity
  Miscalculation
(latent condition)




                                                            Unit Test In
                     Bug Introduced     External API call
                                                            Transition
                     (active failure)    (active failure)
Capacity
  Miscalculation
(latent condition)




                                                            Unit Test In
                     Bug Introduced     External API call
                                                            Transition
                     (active failure)    (active failure)
Capacity
  Miscalculation
(latent condition)




                                                            Unit Test In
                     Bug Introduced     External API call
                                                            Transition
                     (active failure)    (active failure)
                                                        NO FAILURE!
• Better than dominoes, but still linear layers of “defense”
• Helps uncover multiple contributors and latent failures (at
   sharp and blunt ends)
• Better than dominoes, but still linear layers of “defense”
• Helps uncover multiple contributors and latent failures (at
    sharp and blunt ends)
•   Doesn’t explain lineups or orientation of holes
•   Only identifies defects/gaps, nothing more
•   Still encourages judgements of decisions
Better, but still
                                               NOT HELPFUL
• Better than dominoes, but still linear layers of “defense”
• Helps uncover multiple contributors and latent failures (at
    sharp and blunt ends)
•   Doesn’t explain lineups or orientation of holes
•   Only identifies defects/gaps, nothing more
•   Still encourages judgements of decisions
Multiple Contributors

 “each necessary but only jointly sufficient”
Resultant Versus Emergent
Systemic
                Database
Router                     Memcache


    Webserver
Systemic
                Database
Router                        Memcache


    Webserver
                            Feature
                           Roadmap
Systemic
                Database
Router                        Memcache
                                  Last Round
    Webserver                     of Funding
                            Feature
                           Roadmap
Systemic                        Dashboard
                                 Design

                Database
Router                        Memcache
                                  Last Round
    Webserver                     of Funding
                            Feature
                           Roadmap
Systemic                          Dashboard
                                    Design

                   Database
  Router                         Memcache
                                     Last Round
       Webserver                     of Funding
                               Feature
                              Roadmap



DBA’s car
Systemic                          Dashboard
                                    Design

                   Database
  Router                         Memcache
                                     Last Round
       Webserver                     of Funding
                               Feature
                              Roadmap


             No Eng
DBA’s car    Training
Systemic                           Dashboard
                                     Design

                    Database
  Router                          Memcache
                                      Last Round
        Webserver                     of Funding
                                Feature
  Email is
                               Roadmap
   down

              No Eng
DBA’s car     Training
Systemic                           Dashboard
                                     Design

                    Database
  Router                          Memcache
                                      Last Round
        Webserver                     of Funding
                                Feature
  Email is
                               Roadmap
   down
                                           Entire
                                          Ops Team
              No Eng                        Is At
DBA’s car     Training                    Velocity
Systemic                               Dashboard
                                         Design

                    Database
  Router                            Memcache
                                         Last Round
        Webserver                        of Funding
                                 Feature
  Email is
                                Roadmap
   down
                                             Entire
                                            Ops Team
              No Eng       Techcrunch         Is At
DBA’s car     Training       Article        Velocity
Systemic Hiring
                                        Dashboard
                                         Design
        Difficulties Database
  Router                            Memcache
                                         Last Round
        Webserver                        of Funding
                                 Feature
  Email is
                                Roadmap
   down
                                             Entire
                                            Ops Team
              No Eng       Techcrunch         Is At
DBA’s car     Training       Article        Velocity
Systemic Hiring
                          S3 is slow    Dashboard
                                         Design
        Difficulties Database
  Router                               Memcache
                                          Last Round
        Webserver                         of Funding
                                 Feature
  Email is
                                Roadmap
   down
                                             Entire
                                            Ops Team
              No Eng       Techcrunch         Is At
DBA’s car     Training       Article        Velocity
Systemic Hiring
                          S3 is slow    Dashboard
                                         Design
        Difficulties Database
  Router                               Memcache
                                          Last Round
        Webserver                         of Funding
                                 Feature
  Email is
                                Roadmap
   down
                                             Entire
                                            Ops Team
              No Eng       Techcrunch         Is At
DBA’s car     Training       Article        Velocity
Systemic
Systemic
Systemic
Systemic
Systemic
Systemic
Systemic
Functional Resonance
In isolation, components act within bounds.


Interconnected, they produce emerging
behaviors.
Causes Are Constructed,
Not Found
 WYLFIWYF
 Pre-conceived notions on “causes” and behaviors
Contributors, not causes
There is no root cause.
LEARNING
Quantifying Response
Time to detect?
Time for escalation, internal notification?
Time to notify the public?
Time to graceful degradation? (feature off)
Time to stable/resolve?
Time to all clear?
Qualifying Response
High signal:noise in comm channels?
Troubleshooting fatigue?
Troubleshooting handoff?
All tools on-hand?
Metrics visibility?
Collaborative and skillful communication?
Improvised tooling or solutions?
All Together Now
•   Start/TTD/TTR/Stable/etc.
•   Severity
•   DATA (graphs, IRC, etc.)
•   Description (timeline, etc.)
•   Observations (motivations, latent conditions, etc.)
•   Actions (remediation tickets, followup)
(Anticipation)                   (Response)
    Knowing         Knowing        Knowing      Knowing
      What            What          What          What
    To Expect      To Look For      To Do     Has Happened

                 (Monitoring)                 (Learning)
(Anticipation)                   (Response)
    Knowing         Knowing        Knowing      Knowing
      What            What          What          What
    To Expect      To Look For      To Do     Has Happened

                 (Monitoring)                 (Learning)
Human Error
“...knowledge and error flow from the
same mental sources, only success
can tell one from the other.”
                            Ernest Mach, 1905
Human Error

Nobody comes to work to do a bad job.
Human Error

Useless as a label and ending point.
Human Error

Human error isn’t a cause, it’s
an effect.
Why did it make sense
to the person
at the time?
Error Categories
• Slips
• Lapses
• Mismatches
• Violations
Error Categories
First Stories
“Human error” seen as root cause.
Counterfactuals: saying what they “should”
have done.
Prevention: be “more careful!”
Second Stories
“Human error” seen as systemic vulnerabilities,
deeper inside the organization.

Digging into why it made sense for them to do what they
did, at the time they did it.

Prevention...
Why did it make sense
to the person
at the time?
Why did it make sense
to the person
at the time?
Why did it make sense
to the person
at the time?
Substitution Test

Could peers have made the
same error under the same
circumstances?
WHERE to learn from ?
Two Propositions
100 deploys
6 deploy-related issues
100 > 6
Proposition #1
“Ways in which things go right are special cases
of the ways in which things go wrong.”
Proposition #1
Successes = failures gone wrong
Study the failures, generalize from that.
       data sources: 6 out of 100
Proposition #2
“Ways in which things go wrong are special
cases of the ways in which things go right.”
Proposition #2

Failures = successes gone wrong
Study the successes, generalize from that


data sources:   94 out of 100
94/100 ?
   OR
6/100 ?
What and WHY Do Things
Go RIGHT?
Not just:
                why did we fail?

But also:
            why did we succeed?
Near Misses
Hey everybody -
Don’t be like me. I tried to X, but
because it was no good.
It almost exploded everyone.

So, don’t do: (details about X)
                              Love,
                               Joe
Taking the New View

Recognize that human error is
an attribution.
Taking the New View

Pursue Second Stories.
Taking the New View

Escape Hindsight Bias.
Taking the New View

Understand work as performed
at the sharp end.
Taking the New View
Examine how changes (at all
layers) will produce new
vulnerabilities.
Taking the New View

Use technology to support and
enhance human expertise.
Taking the New View

Tame complexity through new
forms of feedback.
Taking the New View

Realize that your systems are
not inherently safe.
Taking the New View
Human error is an inevitable
by-product of strained
complex systems.
Taking the New View

Human error isn’t at the root of
your safety problems.
Taking the New View

Human error isn’t random.
(Anticipation)                   (Response)
    Knowing         Knowing        Knowing      Knowing
      What            What          What          What
    To Expect      To Look For      To Do     Has Happened

                 (Monitoring)                 (Learning)
Just Culture
Just Culture
Balancing accountability with
learning.
Intentional Malice
Negligence
  Found

         Severity of the Outage
Name
Blame
Shame
Name
Blame
Shame
Name
  WHY?
 Blame
#!@%$&#
Shame
“Must set an example!”
“Has to be some fear that not
doing one’s job correctly could
lead to punishment.”
“Must set an example!”
       Punishing
       Deterrents is a not
“Has to be some fear that
            Losing could
doing one’s job correctly
         Proposition
lead to punishment.”
Holding People Accountable

          !=
     Blaming People
Accountability
    and
  Learning



                 Punishment For Errors
No Bad Apples
Only Bad Theories of Error
Name
  WHY?
 Blame
#!@%$&#
Shame
Signs Of Old View
“Gross Misconduct”
“Carelessness”
“Negligence”
“Egregious Behavior”
“Willful Violations”
Discretionary Spaces
Acceptable



Unacceptable
Acceptable



Unacceptable
Acceptable



Unacceptable
Acceptable



Unacceptable
Acceptable

   (who draws this subjective line?)


Unacceptable
Increase Accountability By
Supporting Learning
Empower People
Let them own their own stories.
Don’t make people pay penalties.
Allow them to educate the organization.
Reduce Uncertainty
Make it clear who defines
acceptable behavior.
Organizational Roots

Accountability =
Responsibility + Requisite Authority
(Anticipation)                   (Response)
    Knowing         Knowing        Knowing      Knowing
      What            What          What          What
    To Expect      To Look For      To Do     Has Happened

                 (Monitoring)                 (Learning)
(Thanks, Fellas)



Dr. Erik Hollnagel   Dr. David Woods Dr. Sidney Dekker Dr. Richard Cook
Homework!
We Want    YOU
    etsy.com/careers
•
                                             Photo Credits
    http://www.flickr.com/photos/51035644987@N01/2678090600/
•   http://www.flickr.com/photos/67196253@N00/2941655917/
•   http://www.flickr.com/photos/stirwise/417629641
•   http://www.flickr.com/photos/38383999@N06/3888057995/
•   http://www.flickr.com/photos/94443490@N00/361543080/
•   http://www.flickr.com/photos/7729940@N06/4333396494/
•   http://www.flickr.com/photos/cpstorm/167418602
•   http://www.flickr.com/photos/63474264@N00/4366221069/
•   http://www.flickr.com/photos/proimos/4199675334
•   http://www.flickr.com/photos/30475691@N07/2862060992/
•   http://www.flickr.com/photos/14663487@N00/797755046/
•   http://www.flickr.com/photos/25080113@N06/5361445631/
THE END

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