poor technical decisions. •A weak culture can’t be saved by using the best technology. •Culture is reinforced by, and reinforces your tooling and process. Why focus on culture? 13
it is about continued redrafting of an emerging narrative so that it becomes more comprehensive, incorporates more of the observed data, and is more resilient in the face of criticism. Ongoing semsemaking in PostMortems 34
Cook, Richard I. "How complex systems fail." Cognitive Technologies Laboratory, University of Chicago. Chicago IL (1998) Weick, Karl E. Sensemaking in organizations. Vol. 3. Sage, 1995. Tversky, Amos and Kahneman, Daniel. “Judgment under Uncertainty: Heuristics and Biases.” Science, September 1974, 185(4157), pp. 1124–31. ‘Life After Human Error’ Steven Shorrock, Velocity 2014 https://www.youtube.com/watch? v=STU3Or6ZU60 Rasmussen, Jens. "Risk management in a dynamic society: a modelling problem." Safety science 27.2 (1997): 183-213 ‘Revisiting the Swiss Cheese Model of Accidents’, J. Reason, E. Hollnagel, J. Paries Eurocontrol Oct 2006 Sidney Dekker. 2006. The Field Guide to Understanding Human Error. Ashgate Publishing Company, Brookfield, VT, USA.