Code For America Summit 2018

John is an inspiring leader among engineers, but you don’t need to be technical to benefit from his message. Too often in government, we’re told to minimize risk and avoid mistakes at all costs. The reality is that mistakes and accidents happen when working with complex systems; how we respond to them makes all the difference in whether learning from them will happen or not. Systems and the cultures responsible for their operation can become more brittle and locked down, or we can learn from mistakes and become more resilient. The latter path starts with blameless post-incident reviews, part of management principles known as forward-looking accountability and just culture, which come from research in domains like aviation, medicine, and manufacturing. Evolving how we learn from incidents in these ways is critical to turning accidents into real investments in the future.

Transcript

1. “blameless” post-incident reviews
   learning by supporting
   JOHN ALLSPAW
   Principal
   Adaptive Capacity Labs, LLC
   @allspaw
   

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6. How does our software work, really?
   How does our software break, really?
   What do we do to keep it all working?
   

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9. 
   “You should check this out!
   This bit here doesn’t work the way you think it
   does.”
   

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10. • Teams of experts coping with complexity
    • Under competitive/political/production
    pressures
    • High tempo, high consequence scenarios
    • Elements of uncertainty and/or ambiguity
    

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11. Aviation
    Air Traffic Control
    Maritime
    Power Grid & Distribution
    Surgery
    Anesthesia
    Firefighting
    Rail
    Mining
    Explosives
    Space
    

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12. Safety comes from
    people (not tech)
    continually adapting
    their work to the
    situations they find
    themselves in.
    the “messy” details
    

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13. what actions they took at the time
    what effects they observed
    what expectations they had
    what assumptions they made
    their understanding of the timeline of events as they occurred
    the “messy” details
    

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15. So we shouldn’t punish people for making mistakes?
    How do you get “accountability”?
    

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16. This could never
    work in government.
    

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17. ”If people are punished for being honest about what
    transpired, employees will soon learn that the
    personal costs to speaking up far outweigh the
    personal benefits. Improving the safety of a system
    is rooted in information.
    Anything that makes information more available is
    desirable and anything that blocks information should
    be avoided.
    It is for this reason that the Learning Review seeks to
    identify influences and never blame.”
    United States Forest Service Learning Review Guide
    

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18. 4. USE, SHARING, AND RELEASE OF SAFETY INFORMATION
    a. Privileged safety information shall be used for safety purposes only; specifically, preventing
    mishaps and reducing injury and property damage resulting from mishaps.
    b. Privileged safety information shall not be:
    1) Used, shared, or released except as provided in this Instruction.
    2) Used to support disciplinary or adverse administrative action, to determine the
    misconduct or line-of-duty status of any personnel, or as evidence before any
    evaluation board.
    3) Used to determine liability in administrative claims or litigation, whether for or against
    the Government.
    4) Released in response to requests for information pursuant to section 552 of title 5,
    U.S.C. (also known and hereinafter referred to as “FOIA”) (Reference (ab)). Requests
    are submitted in accordance with Reference (w) or in response to discovery requests,
    subpoenas, court orders, or other legal process except as provided in section 10 of this
    enclosure.
    5) Privileged safety information may only be released as provided elsewhere in this
    Instruction or upon specific authorization by the Secretary of Defense.
    DOD Instruction
    6055.7
    

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20. Want to know more about how to do this?
    Come to the breakout session on this topic later today.
    

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