field aiming to create and sustain conditions where resilience can manifest productively. • Resilience is something a system (your organization, not your software) does, not what it has. • Resilience is sustained adaptive capacity, or continuous adaptability to unforeseen situations. • Our world (software) has opportunities to further the state of the field, but face real challenges.
practitioners and researchers from…. Cybernetics Engineering* Ecology Safety Science Biology Control Systems Human Factors & Ergonomics Cognitive Systems Engineering Complexity Science Cognitive Psychology Sociology Operations Research
Law Enforcement Aviation/ATM Space Mining Construction Explosives Firefighting Anesthesia Pediatrics Power Grid & Distribution Military Agencies Software Engineering Resilience Engineering is a Community
Perry Univ of Florida Emergency Medicine Dr. Richard Cook Anesthesiologist Researcher Ivonne Andrade Herrera SINTEF Erik Hollnagel Univ of S. Denmark Gesa Praetorius Linnaeus University Johan Bergström Lund University Sidney Dekker Griffith University Asher Balkin CSEL/OSU Laura Maguire CSEL/OSU
DeVita Casey Rosenthal Nora Jones (me) David Woods Dr. Shawna Perry Dr. Richard Cook Ivonne Herrera Erik Hollnagel Johan Bergström Sidney Dekker Asher Balkin Laura Maguire Gesa Praetorius
unprepared — without an ability to justify it economically! • sustaining the potential for future adaptive action when conditions change • something that a system does, not what it has
in local currency requisite fluency in local language rail schedules bus schedules flight schedules postponing your appointment taking appointment partially via phone until arrival colleague to take your place until you arrive … … …
have: • high degree of surprise • whose consequences were not severe • and look closely at the details about what went into making it not nearly as bad as it could have been • protect and acknowledge explicitly the sources you find
rebuild {server01} first? <laurie> neither box has been touched yet <laurie> and im a tad nervous to do both at once <lisa> wait wait, i thought the X table was small <jeremy> I'm still a bit confused why B and A are different if A got to 0 and B is still at 3099 <tim>: oh I see.. the retry interval is pretty aggressive
from stakeholders with face-saving agenda tend to block deep inquiry • with “medium-severe” incidents the cost of getting details/descriptions of people’s perspectives is low relative to the potential gain • “Goldilocks” incidents are the ideal
the plan no longer fits the situation, as seen from that unit’s perspective; 2. the willingness (even the audacity) to adapt planned activities to work around impasses or to seize opportunities in order to better meet the goals/ intent behind the plan; and 3. when taking the initiative, the unit begins to adapts on its own, using information and knowledge available at that point, without asking for and then waiting for explicit authorization or tasking from other units.
new changes deployed to participate in a new market • unexpected algorithmic mechanisms led to unbounded automated trading activity • team rolls back changes, situation gets much worse • team did not believe it had authority to halt system • $440M loss in ~20 minutes
to contact details for everyone in your organization? • what actions do you need permission to take? • what repercussions exist for “violating” procedures or compliance rules? • can you anticipate what “neighboring” teams may need in the future that you have (expertise, staff, resources, etc.) and can donate to them before they need it, even if it sacrifices some of your local goals?
• all incident data is reactive and scoped to unwanted events; they tell us nothing about wanted situations • “trending” these numbers tell us nothing about learning, prevention, expertise, proactiveness, or adaptive capacity. Inconvenient realities of shallow data
aiming to create and sustain conditions where resilience can manifest productively. • Resilience is something a system (your organization, not your software) does, not what it has. • Resilience is sustained adaptive capacity, or continuous adaptability to unforeseen situations. • Our world (software) has opportunities to further the state of the field, but face real challenges.