Let's Safety Dance

I hate computers. How many times have you heard those words? Or said them yourself. Systems crash and go boom all the time. The easiest thing to do is to blame the person touching the keyboard when it happens. Especially when that person touching the keyboard is you. But how do we build safer systems? How do we build humane systems, systems that actually engage and even delight the user? Sidney Dekker says "Safety improvements come from organizations monitoring the gap between procedures and practice". How can you build a system for safety if the way the system is designed isn't actually how it's used. Of course it doesn't work, you were doing it wrong. We have to stop shoving users into systems with procedures that aren't based on reality.

In this talk I address these questions through my experience building tools for developers. Every tool works in an ideal world and on my machine. But the hard part is building tools that "work" even when they don't. Understanding the gap between procedure and practice can be a real challenge, and if you don't approach that problem with a big dose of empathy you won't have much luck closing that gap.

Important Note: In this talk I conflate the idea that Safety I & Safety II and the Old View/New View are equivalent ideas. That is incorrect, what I was mostly talking about in that section of the talk is Dekker's New/Old Views on Safety. If you're interested in learning more about Erik Hollnagel's Safety I and Safety II check out his paper http://www.resilienthealthcare.net/A_tale_of_two_safeties.pdf
Thanks to John Allspaw for so kindly pointing this out to me.

Video Link: https://www.youtube.com/watch?v=ZFdN20G65NA&feature=youtu.be

Transcript

1. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek LET’S SAFETY DANCE! FINDING SAFETY IN AN UNSAFE WORLD
3. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek ANDY FLEENER ! ! @andyfleener github.com/anfleene Software Engineer
4. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek SAFETY?
5. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek THE OLD VIEW
6. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek THE NEW VIEW
7. @andyfleener Creative Commons Image: Fons Heijnsbroek LEARN & IMPROVE B BLAME & PUNISH @andyfleener Creative Commons Image: Fons Heijnsbroek VS
8. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek WHY ARE YOU DANCING?
9. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek DANCING REQUIRES BALANCE
10. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek “Complex systems are trade-offs between multiple irreconcilable goals (e.g safety and efficiency)” - Sidney Dekker
11. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek WHAT DOES SAFETY MEAN FOR SOFTWARE?
12. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek I HATE COMPUTERS
13. @andyfleener Creative Commons Image: Fons Heijnsbroek SOFTWARE IS A 
 COMPLEX SYSTEM @andyfleener Creative Commons Image: Fons Heijnsbroek
14. @andyfleener Creative Commons Image: Fons Heijnsbroek SYSTEMS ARE INHERENTLY UNSAFE @andyfleener Creative Commons Image: Fons Heijnsbroek
15. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek THIS IS WHY WE CAN’T HAVE NICE THINGS
16. @andyfleener Creative Commons Image: Fons Heijnsbroek SYSTEMS CAUSE FAILURE @andyfleener Creative Commons Image: Fons Heijnsbroek
17. @andyfleener Creative Commons Image: Fons Heijnsbroek ORGANIZATIONS ARE COMPLEX SYSTEMS @andyfleener Creative Commons Image: Fons Heijnsbroek
18. @andyfleener Creative Commons Image: Fons Heijnsbroek HUMAN FACTORS @andyfleener Creative Commons Image: Fons Heijnsbroek
19. @andyfleener Creative Commons Image: Fons Heijnsbroek TO ERR IS HUMAN @andyfleener Creative Commons Image: Fons Heijnsbroek
20. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek BECOME COMFORTABLE WITH FAILURE
21. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek NO ONE COMES TO WORK TO DO A BAD JOB
22. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek HOW DO WE CREATE SAFER SYSTEMS?
23. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek LEARN FROM FAILURE
24. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek START ASSUMING THEY DID THE RIGHT THING
25. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek WATCH OUT FOR HINDSIGHT BIAS
26. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek "CAUSE IS SOMETHING WE CONSTRUCT NOT FIND” - DEKKER
27. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek FOSTER A CULTURE OF LEARNING
28. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek SHORTEN FEEDBACK LOOPS
29. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek PROCEDURE B PRACTICE VS
30. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek ACCEPT THEY ARE DIFFERENT
31. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek MIND THE GAP
32. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek STUDY THE PRACTICE
33. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek CHANGE THE SYSTEM
34. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek EVERY CHANGE HAS AN IMPACT
35. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek ORGANIZATIONAL CHANGE HAS THE BIGGEST IMPACT
36. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek BUT WHAT ABOUT SAFETY?
37. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek SAFETY IS CONTINUOUS IMPROVEMENT
38. @andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek Preaccident Investigation Podcast - Todd Conklin The Field Guide to Understanding Human Error - Sidney Dekker Humanistic Systems - Steven Shorrock Failure Is An Option - Ian Malpass
39. THANKS!