Silicon Happy Valley 2016 - Presentation on organizational learning in the face of mistakes.

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Organizational Learning
When Things Go Wrong
Matthew Graham
@lapsu #SHV16
BS CompEng 2000
http://www.etsy.com
SILICON HAPPY VALLEY 2016

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Pilot
Operator
Human Error

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Old View vs. New View
TAKEAWAYS

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Old View vs. New View
TAKEAWAYS
Drawbacks
Symptoms

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Old View vs. New View
TAKEAWAYS
Drawbacks
Symptoms
Approaches
Benefits

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Organizational Learning
Healthy Culture
Path to Resilience
NEW VIEW BENEFITS

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SECTION 1
Old View vs. New View

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What is “Human Error”?
Why do humans make errors?
What to do when errors are made?

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What is “Human Error”?

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OLD VIEW
Systems are Reliable
People are Unreliable

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Human Error
is a Symptom
NEW VIEW

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Dead BatteryDead Battery

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Indicator BellIndicator Bell

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Auto OfAuto Of

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Why do humans make errors?

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OLD VIEW
Because They're
Bad Humans

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“What did they do wrong?”

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A Bad Apple
at Work
A Bad Apple
at Work

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People Want
To Succeed
NEW VIEW

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People Have Reasons:
Tools, Tasks, Situation
NEW VIEW

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“What was the reason
for taking that action?”
NEW VIEW

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What to do when errors are made?

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OLD VIEW: WHAT TO DO WHEN ERRORS ARE MADE?
Mistakes Have
Consequences

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Errors Are
Opportunity
NEW VIEW: WHAT TO DO WHEN ERRORS ARE MADE?

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SECTION 2
Analyzing Failure
1) Identify Symptoms of Old View
2) Replace with New View Approaches

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SYMPTOM OF OLD VIEW
Retrospection

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See Sequence of Events in Reverse
Discount Other Possible Outcome
Perspective of Many Individuals
Knowledge of Outcome
RETROSPECTION

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OUTCOME BIAS
Judging actions more harshly
once the outcome is known

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A Pitcher
Catching
Fly Balls?
A Pitcher
Catching
Fly Balls?

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HINDSIGHT BIAS
Judge a past outcome as
predictable/knowable/obvious

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ForesightForesight
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HindsightHindsight

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Hindsight Foresight≠

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Review Events in Order
Available Info Only
NEW VIEW: RETROSPECTION

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Too Close to the IslandToo Close to the Island

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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

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Meeting
Deadlines?
Meeting
Deadlines?

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Upon
Failure?
Upon
Failure?

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Procedures Practice≠
NEW VIEW: PROCEDURAL ADAPTATIONS

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'Embarrassing human error'
knocks out Telstra mobile data
and calls nation-wide
CNET HEADLINE 2016-02-16

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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."

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Why didn't individual follow procedure?
Does anyone ever follow procedure?
Did individual know of procedure?
NEW VIEW

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COUNTERFACTUALS AKA
Shoulda
Coulda
Woulda

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SUBJUNCTIVE
Subjunctive forms of verbs are typically used to
express various states of unreality

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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."

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Whatever happened
is what happened
NEW VIEW

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Why is that what happened?
NEW VIEW

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Assume Good Intentions
Look to Individual for Info
Look to System for Problems
NEW VIEW: TELSTRA

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Recovery took 3 hours;
what caused delays?
NEW VIEW: TELSTRA

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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

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SECTION 3
Response to Error

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SYMPTOM OF OLD VIEW
Justice

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OLD VIEW: PUNSHMENT
Stop Hearing
About Errors

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Punishment XOR Learning

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Learning and Resilience:
New View Benefits
NEW VIEW: RESPONSE

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Share Failure Experience
Leadership Too

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Individual Errs
Organization Learns
NEW VIEW: LEARNING

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Errors identified sooner?
Faster recovery?
System provide correct action?
Redundancy?
NEW VIEW: RESILIENCE

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Less Process & Approval
Work Without Obstruction
TRUST IN SUCCESS CONTEXT

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SUMMARY
Identify Symptoms of Old View
Apply New View Approaches
Learn as an Organization
Improve Resilience

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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/

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Questions?
THANK YOU
Matthew Graham
@lapsu
BS CompEng 2000
http://www.etsy.com