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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek LET’S SAFETY DANCE! FINDING SAFETY IN AN UNSAFE WORLD

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek ANDY FLEENER ! ! @andyfleener github.com/anfleene Software Engineer

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek SAFETY?

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek THE OLD VIEW

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek THE NEW VIEW

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@andyfleener Creative Commons Image: Fons Heijnsbroek LEARN & IMPROVE B BLAME & PUNISH @andyfleener Creative Commons Image: Fons Heijnsbroek VS

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek WHY ARE YOU DANCING?

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek DANCING REQUIRES BALANCE

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek “Complex systems are trade-offs between multiple irreconcilable goals (e.g safety and efficiency)” - Sidney Dekker

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek WHAT DOES SAFETY MEAN FOR SOFTWARE?

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek I HATE COMPUTERS

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@andyfleener Creative Commons Image: Fons Heijnsbroek SOFTWARE IS A 
 COMPLEX SYSTEM @andyfleener Creative Commons Image: Fons Heijnsbroek

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@andyfleener Creative Commons Image: Fons Heijnsbroek SYSTEMS ARE INHERENTLY UNSAFE @andyfleener Creative Commons Image: Fons Heijnsbroek

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek THIS IS WHY WE CAN’T HAVE NICE THINGS

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@andyfleener Creative Commons Image: Fons Heijnsbroek SYSTEMS CAUSE FAILURE @andyfleener Creative Commons Image: Fons Heijnsbroek

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@andyfleener Creative Commons Image: Fons Heijnsbroek ORGANIZATIONS ARE COMPLEX SYSTEMS @andyfleener Creative Commons Image: Fons Heijnsbroek

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@andyfleener Creative Commons Image: Fons Heijnsbroek HUMAN FACTORS @andyfleener Creative Commons Image: Fons Heijnsbroek

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@andyfleener Creative Commons Image: Fons Heijnsbroek TO ERR IS HUMAN @andyfleener Creative Commons Image: Fons Heijnsbroek

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek BECOME COMFORTABLE WITH FAILURE

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek NO ONE COMES TO WORK TO DO A BAD JOB

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek HOW DO WE CREATE SAFER SYSTEMS?

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek LEARN FROM FAILURE

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek START ASSUMING THEY DID THE RIGHT THING

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek WATCH OUT FOR HINDSIGHT BIAS

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek "CAUSE IS SOMETHING WE CONSTRUCT NOT FIND” - DEKKER

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek FOSTER A CULTURE OF LEARNING

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek SHORTEN FEEDBACK LOOPS

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek PROCEDURE B PRACTICE VS

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek ACCEPT THEY ARE DIFFERENT

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek MIND THE GAP

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek STUDY THE PRACTICE

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek CHANGE THE SYSTEM

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek EVERY CHANGE HAS AN IMPACT

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek ORGANIZATIONAL CHANGE HAS THE BIGGEST IMPACT

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek BUT WHAT ABOUT SAFETY?

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek SAFETY IS CONTINUOUS IMPROVEMENT

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@andyfleener Creative Commons Image: Fons Heijnsbroek @andyfleener Creative Commons Image: Fons Heijnsbroek Preaccident Investigation Podcast - Todd Conklin The Field Guide to Understanding Human Error - Sidney Dekker Humanistic Systems - Steven Shorrock Failure Is An Option - Ian Malpass

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THANKS!