Helping your org learn from failures

Transcript

1. Helping your org learn from failures
2. quick show of hands: - who has had a client site go down? https://www.flickr.com/photos/ldsykora/2414497811/sizes/o
3. quick show of hands: - who got blamed for that? - how did that make you feel? - did your organisation learn anything from that experience? https://www.flickr.com/photos/leviphotos/2332987961/sizes/o
4. Advantages of learning orgs
5. High quality feedback from front lines
6. Focus on quality & delivery
7. Less defending of decisions
8. 3 factors that inhibit learning
9. Blame
10. Language
11. Sharing
13. Blame
14. “you were responsible for this failure”
15. neglectful, inattentive, derelict of duty
16. Bad apples https://www.flickr.com/photos/cogdog/20891088578/
17. Ignores a truth
18. sometimes bad things happen and nobody is to blame
19. things go right more often than they go wrong Embracing complexity
21. http://www.youtube.com/watch?v=Ahg6qcgoay4
22. http://www.youtube.com/watch?v=Ahg6qcgoay4
23. Confirmation bias seek information that reinforces an existing view
24. Confirmation bias ignore alternative explanations
25. Confirmation bias interpret ambiguous information in favour of existing assumptions
26. “you were responsible for this failure”
27. neglectful, inattentive, derelict of duty
29. • MH17 tragedy reveals need for flight path overhaul • Flight MH17 took abandoned flight path • MH17 flightpath questioned as Malaysia mourns second airline tragedy • Flight MH17 ‘could have avoided Ukrainian airspace for $66 per passenger’ • Why was MH17’s flight path over a conflict zone? http://www.news.com.au/travel/travel-updates/mh17-tragedy-reveals-need-for-flight-path-overhaul/story-e6frfq80-1227003997977 http://www.skynews.com.au/news/top-stories/2014/07/18/flight-mh17-took-abandoned-flight-path.html http://www.abc.net.au/news/2014-07-21/mh17-flightpath-questioned-as-malaysia-mourns/5613018 http://www.dailymail.co.uk/news/article-2699452/Avoiding-MH17-plane-disaster-cost-Malaysia-Airlines-just-66-passenger.html http://www.pbs.org/newshour/rundown/mh17s-flight-path-area-fighting/
30. Hindsight bias “knew it all along” effect
31. Hindsight bias alter memories to fit a narrative of how you perceived and reacted to events
32. Hindsight bias talk about events with knowledge of the outcome
33. “you were responsible for this failure”
34. neglectful, inattentive, derelict of duty
35. Hindsight bias is your culture killer
37. Language
38. Language hacks to minimise blame
39. why vs what
40. words as framing devices
41. investigations & retrospectives & learning reviews & brainstorming & post mortems
42. questions to help you blame
43. questions to help you learn
44. Inquiry or CYA?
45. why
46. justifying actions
47. “why did you reboot the instances?”
48. “why didn’t you check backups?”
49. attribute & apportion blame
50. focuses inquiry on people
51. counterfactuals
52. “why didn’t you check backups?”
54. Fundamental Attribution Error
55. people’s actions are explained by their personality, not their context
56. what
57. uncovers reasoning
58. “what did you think was happening?”
59. “what did you do next?”
60. “what made the most sense?”
61. “what was going through your mind?”
62. build empathy with actors in your complex systems
63. build empathy for people
64. encourages explaining in terms of foresight
65. local rationality
66. “people make decisions given the information available to them at the time”
69. what did the inside of the tunnel look like?
70. Sharing
71. Share experiences
72. investigations & retrospectives & learning reviews & brainstorming & post mortems
73. start at the beginning
74. Safe environments
75. https://www.flickr.com/photos/thomashawk/10490113913/sizes/o
76. Work as Imagined vs Work as done
77. – Niels Bohr We need many partially overlapping and always somehow contradictory descriptive layers to approximate a rendition of reality
79. things go right more often than they go wrong Embracing complexity
80. beware of confirmation bias & hindsight bias
81. “what” is your tool for fostering inquiry
82. investigations & retrospectives & learning reviews & brainstorming & post mortems
83. start at the beginning
84. I’m Lindsay @auxesis
85. Thank you! Liked the talk? Let @auxesis know.