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DevOpsPorto Meetup9: There is no such thing as human error by João Miranda

DevOpsPorto
October 14, 2017

DevOpsPorto Meetup9: There is no such thing as human error by João Miranda

Talk delivered by João Miranda

DevOpsPorto

October 14, 2017
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  1. Human Error
    There is no such things as...

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  2. Ego Self-Massage
    17 years in the IT world: developer, scrum master, ALM team
    lead, agile coach, solution architect, engineering manager
    Manages (huh... tries to cope with)
    10 Scrum teams
    Co-organizes DevOps Lisbon meetup
    Loves Software Engineering

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  3. Favourite journalist question after an
    accident?

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  4. “Was it a human or a technical error?”

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  5. “Employing simplicity thinking and linear logic,
    the official findings and the judicial rulings
    determined that the train driver was
    “exclusively” responsible for the crash.”*
    * Disaster complexity and the Santiago de
    Compostela train derailment

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  6. Amazon’s outage
    “Amazon’s massive
    AWS outage was
    caused by human
    error.
    One incorrect command
    and the whole internet
    suffers.”
    Recode. March 2, 2017

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  7. “During the deployment of the new code, however, one of
    Knight’s technicians did not copy the new code to one of the
    eight SMARS computer servers. Knight did not have a
    second technician review this deployment (...)”
    Knightmare: A DevOps Cautionary Tale
    Knight Capital Loses $440 Million in 30 Minutes

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  8. Consumer credit reporting agency.
    Info on 800 million consumers.

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  9. Hackers exposed the Social Security
    numbers, drivers licenses and other
    sensitive info of 143 million customers.

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  10. … yup… you’ve guessed it...

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  11. “Former Equifax CEO says breach boiled
    down to one person not doing their job.”
    https://techcrunch.com/2017/10/03/former-equifax-ceo-says-breach-boiled-down-to-one-person-not-doing-their-job/

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  12. “It’s well established that
    accidents cannot be attributed
    to a single cause or (...) a
    single individual”
    Industrial Accident Prevention, H.W. Heinrich, Dan Petersen, Nestor Roos, 1980 (5th
    edition), McGraw-Hill Book Company (ISBN 0-07-028061-4)

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  13. Coping With Complexity
    Humans are a feature of complex systems. They solve the
    most complex issues (not computers), but they also have
    some blind spots.

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  14. Cognitive Demands of a Domain
    ● Dynamism
    ● Number of parts and extensiveness of its interconnections
    ● Uncertainty
    ● Risk
    A domain is complex if high in all of these dimensions.
    * David D. Woods, “Coping with complexity: The psychology of human behaviour in complex systems” (1988)

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  15. Failure to Adapt to New Events
    People may get fixated on initial assessments.
    * David D. Woods, “Coping with complexity: The psychology of human behaviour in complex systems” (1988)

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  16. “…[people] have difficulty in dealing with exponential
    developments (hard to imagine how fast things can
    change, or accelerate).”
    Dietrich Dörner, “On The Difficulties People Have In Dealing With Complexity” (1980),
    via John Allspaw, “Resilience Engineering Part II: Lenses” (2012)

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  17. Failure to Use External Guidance to
    Direct Focus
    E.g.: Start treating a cause before treating more pressing
    consequences.
    * David D. Woods, “Coping with complexity: The psychology of human behaviour in complex systems” (1988)

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  18. Failures of Prospective Memory
    Forgetting to recall an intention for some future point in time.
    * David D. Woods, “Coping with complexity: The psychology of human behaviour in complex systems” (1988)

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  19. Treating Interconnected Events as
    Independent
    E.g.: Failing to consider how a recently deployed change to
    the Users API may be causing the Check-out process to fail.
    * David D. Woods, “Coping with complexity: The psychology of human behaviour in complex systems” (1988)

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  20. “…[people] tend to
    think in causal series as opposed to causal nets
    (A, therefore B) ->
    (A and B, therefore C and D, therefore E and A and F)”
    Dietrich Dörner, “On The Difficulties People Have In Dealing With Complexity” (1980),
    via John Allspaw, “Resilience Engineering Part II: Lenses” (2012)

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  21. Over Reliance on Familiar Signs
    “The site is so slow. It must be the database again.”
    * David D. Woods, “Coping with complexity: The psychology of human behaviour in complex systems” (1988)

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  22. ● Human error is cause of failure
    ● Engineered systems are safe
    ● Make progress by protecting systems from unreliable
    humans
    “Old” View Of Human Error

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  23. It’s so easy and tempting to point fingers
    and find scapegoats after the fact.
    But...

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  24. ...we’re humans. We’re not rational or
    objective beings.
    Here’s why.

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  25. Hindsight Bias
    “The inclination, after an event has ocurred, to see the
    event as having been predictable, despite there having
    been little or no objective basis for predicting it.”
    “Hindsight bias”

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  26. It’s so obvious! How could
    have they missed it?

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  27. Fundamental Attribution Error
    “Our tendency to explain someone’s behaviour based on
    internal factors, such as personality or disposition, and to
    underestimate the influence that external factors, such as
    situational influences (...).”
    “Fundamental Attribution Error - Definition & Overview”

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  28. It’s easier to change people than basic
    beliefs about a system.

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  29. “The human tendency to create possible alternatives to life
    events that have already occurred.
    They are thoughts that consist of ‘If I had only’.”
    “Counterfactual Thinking”
    Counterfactuals

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  30. Counterfactuals can affect people’s
    emotions, e.g.: regret, guilt or relief.
    They can also affect how they decide
    who deserves blame and responsibility.

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  31. Stressing what was not done explains
    nothing about what actually happened,
    or why.

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  32. What can we do?

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  33. Local Rationality Principle
    “People do things that make sense to them given their
    goals, understanding of the situation and focus of attention
    at that time.
    Work needs to be understood from the local perspectives of
    those doing the work.”
    “Local Rationality”

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  34. The local decision is always right.

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  35. Normal people, doing normal things.

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  36. So… can we really find “the” cause?

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  37. Scott A. Snook, Friendly Fire: The Accidental Shootdown of U.S. Black Hawks over Northern Iraq

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  38. We don’t find
    cause.
    We select cause.

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  39. ● Human error as symptom of failure
    ● Safety is not inherent in systems
    ● Human error connected to features of people, tools, tasks
    and operating environment
    “New” View On Human
    Error

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  40. How Organizations Process Information
    Pathological Bureaucratic Generative
    Power-oriented Rule-oriented Performance-oriented
    Low co-operation Modest co-operation High co-operation
    Messengers shot Messengers neglected Messengers trained
    Responsibilities shirked Narrow responsibilities Risks are shared
    Bridging discouraged Bridging tolerated Bridging encouraged
    Failure leads to scapegoating Failure leads to justice Failure leads to inquiry
    Novelty crushed Novelty leads to problems Novelty implemented
    Ron Westrum, “A typology of organisational cultures” (2004)

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  41. Four Needs
    an accident report must fulfill
    Sidney Dekker, “The psychology of accident investigation: epistemological, preventive, moral and existential meaning-making” (2014)

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  42. Epistemological
    Preventive
    Moral
    Existential
    Most of the time they are in conflict.

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  43. The way we look at human error focuses
    on moral and existential needs.

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  44. And what do we get by focusing on those
    two needs?

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  45. Blame Culture
    Real or perceived. It doesn’t
    matter.

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  46. Learning from failure
    is at least as important
    as fulfilling moral and
    existential needs.

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  47. A Systematic Approach to Learn From
    Past Events
    Five steps: from context-specific to concept-dependent.
    Sidney Dekker, “Reconstructing human contributions to accidents: the new view on error and performance.” (2014)

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  48. 1. Layout Sequence of Events in
    Context-Specific Language
    Data about an incident reveals a sequence of
    activities — human observations, actions,
    assessments, decisions, as well as changes in the
    state of the process or system.

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  49. 2. Divide Sequence of Events into
    Episodes
    If the accident evolves over a long period of time.

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  50. 3. Find Out How the World Looked or
    Changed During Each Episode
    Find out what their process was doing and what data
    was available. Couple behaviour with situation.

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  51. 4. Identify People's Goals, Focus of
    Attention and Knowledge Active at the
    Time
    What people know and what they try to accomplish
    (their goals) determines where they will look, hence
    the data that is observable to them.

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  52. 5. Step Up to a Conceptual Description
    It’s crucial so that we can learn from failures and
    identify commonalities between different events.

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  53. Now go and make your
    organization more
    humane...

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  54. ...and Resilient!

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  55. Human
    Factors &
    System
    Safety
    MsC and Learning Labs

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