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Organizational LearningWhen Things Go Wrong

Matthew Graham@lapsu #SHV16

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

SILICON HAPPY VALLEY 2016

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PilotOperator

Human Error

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Old View vs. New View

TAKEAWAYS

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Old View vs. New View

TAKEAWAYS

DrawbacksSymptoms

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Old View vs. New View

TAKEAWAYS

DrawbacksSymptoms

ApproachesBenefits

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Organizational Learning

Healthy Culture

Path to Resilience

NEW VIEW BENEFITS

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S E C T I O N 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 Appleat Work

A Bad Appleat 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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S E C T I O N 2

Analyzing Failure1) 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 harshlyonce the outcome is known

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A PitcherCatchingFly Balls?

A PitcherCatchingFly 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 SureNothing Bad

Happens Ever

Make SureNothing Bad

Happens Ever

Make $ Make $

NEW VIEW: BALANCING BUSINESS PRIORITIES

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MeetingDeadlines?

MeetingDeadlines?

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UponFailure?

UponFailure?

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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

ShouldaCouldaWoulda

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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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S E C T I O N 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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S U M M A RY

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/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/

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Questions?

THANK YOU

Matthew Graham@lapsu

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