organizational learning when things go wrong

1

Organizational LearningWhen Things Go Wrong

Matthew Graham@lapsu #SHV16

BS CompEng 2000http://www.etsy.com

SILICON HAPPY VALLEY 2016

2

PilotOperator

Human Error

3

4

5

Old View vs. New View

TAKEAWAYS

6

Old View vs. New View

TAKEAWAYS

DrawbacksSymptoms

7

Old View vs. New View

TAKEAWAYS

DrawbacksSymptoms

ApproachesBenefits

8

Organizational Learning

Healthy Culture

Path to Resilience

NEW VIEW BENEFITS

9

S E C T I O N 1

Old View vs. New View

10

What is “Human Error”?

Why do humans make errors?

What to do when errors are made?

11

What is “Human Error”?

12

OLD VIEW

Systems are Reliable

People are Unreliable

1414

15

Human Error

is a Symptom

NEW VIEW

1616

Dead BatteryDead Battery

1717

Indicator BellIndicator Bell

1818

Auto OfAuto Of

19

Why do humans make errors?

20

OLD VIEW

Because They're

Bad Humans

2121

“What did they do wrong?”

2222

A Bad Appleat Work

A Bad Appleat Work

23

People Want

To Succeed

NEW VIEW

24

People Have Reasons:

Tools, Tasks, Situation

NEW VIEW

25

“What was the reason

for taking that action?”

NEW VIEW

26

What to do when errors are made?

27

OLD VIEW: WHAT TO DO WHEN ERRORS ARE MADE?

Mistakes Have

Consequences

28

Errors Are

Opportunity

NEW VIEW: WHAT TO DO WHEN ERRORS ARE MADE?

29

S E C T I O N 2

Analyzing Failure1) Identify Symptoms of Old View

2) Replace with New View Approaches

30

SYMPTOM OF OLD VIEW

Retrospection

31

See Sequence of Events in Reverse

Discount Other Possible Outcome

Perspective of Many Individuals

Knowledge of Outcome

RETROSPECTION

32

OUTCOME BIAS

Judging actions more harshlyonce the outcome is known

3333

A PitcherCatchingFly Balls?

A PitcherCatchingFly Balls?

34

HINDSIGHT BIAS

Judge a past outcome as predictable/knowable/obvious

3636

ForesightForesight

36

HindsightHindsight

37

Hindsight Foresight≠

38

Review Events in Order

Available Info Only

NEW VIEW: RETROSPECTION

393939

Too Close to the IslandToo Close to the Island

40

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

4141

Make SureNothing Bad

Happens Ever

Make SureNothing Bad

Happens Ever

Make $ Make $

NEW VIEW: BALANCING BUSINESS PRIORITIES

4343

MeetingDeadlines?

MeetingDeadlines?

4444

UponFailure?

UponFailure?

45

Procedures Practice≠

NEW VIEW: PROCEDURAL ADAPTATIONS

46

'Embarrassing human error'

knocks out Telstra mobile data

and calls nation-wide

CNET HEADLINE 2016-02-16

48

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."

49

Why didn't individual follow procedure?

Does anyone ever follow procedure?

Did individual know of procedure?

NEW VIEW

50

COUNTERFACTUALS AKA

ShouldaCouldaWoulda

51

SUBJUNCTIVE

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

52

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."

53

Whatever happened

is what happened

NEW VIEW

54

Why is that what happened?

NEW VIEW

56

Assume Good Intentions

Look to Individual for Info

Look to System for Problems

NEW VIEW: TELSTRA

57

Recovery took 3 hours;

what caused delays?

NEW VIEW: TELSTRA

58

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

61

S E C T I O N 3

Response to Error

62

SYMPTOM OF OLD VIEW

Justice

64

OLD VIEW: PUNSHMENT

Stop Hearing

About Errors

65

Punishment XOR Learning

66

Learning and Resilience:

New View Benefits

NEW VIEW: RESPONSE

6767

Share Failure Experience

Leadership Too

68

Individual Errs

Organization Learns

NEW VIEW: LEARNING

69

Errors identified sooner?

Faster recovery?

System provide correct action?

Redundancy?

NEW VIEW: RESILIENCE

70

Less Process & Approval

Work Without Obstruction

TRUST IN SUCCESS CONTEXT

71

S U M M A RY

Identify Symptoms of Old View

Apply New View Approaches

Learn as an Organization

Improve Resilience

7272

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/Costa-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/

73

Questions?

THANK YOU

Matthew Graham@lapsu

BS CompEng 2000http://www.etsy.com