Slide 1

Slide 1 text

Fallible Humans Dealing With Failure In The Absence Of Scapegoats Ian Malpass, Etsy @indec

Slide 2

Slide 2 text

"Jerusalem Ugglan 1". Licensed under Public domain via Wikimedia Commons - http://commons.wikimedia.org/wiki/File:Jerusalem_Ugglan_1.jpg

Slide 3

Slide 3 text

By Rodhullandemu (Own work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons GET IN THE CAR GET IN THE CAR NO TIME TO EXPLAIN NO TIME TO EXPLAIN

Slide 4

Slide 4 text

“Fire of Troy" by Kerstiaen de Keuninck (Coninck) - http://fotki.yandex.ru/users/fchstudents/view/133880?page=69. Licensed under Public domain via Wikimedia Commons

Slide 5

Slide 5 text

It’s not me, it’s you

Slide 6

Slide 6 text

Dev Ops Legal Marketing Support Finance Security

Slide 7

Slide 7 text

Dev Ops Legal Marketing Support Finance Security

Slide 8

Slide 8 text

With the unknown, one is confronted with danger, discomfort, and care; the first instinct is to abolish these painful states. First principle: any explanation is better than none. ! Friedrich Nietzsche, The Twilight Of The Idols

Slide 9

Slide 9 text

A person who has been punished is not thereby simply less inclined to behave in a given way; at best, he learns how to avoid punishment. ! B. F. Skinner, Beyond Freedom and Dignity

Slide 10

Slide 10 text

Failure is an emergent property of a complex system

Slide 11

Slide 11 text

Chalk Farm Banksy by grahamc99 https://flic.kr/p/39M4pM

Slide 12

Slide 12 text

We should learn from our mistakes

Slide 13

Slide 13 text

You don’t come to work to do a bad job

Slide 14

Slide 14 text

Get the feature out on time Don’t have any bugs Don’t use too many resources

Slide 15

Slide 15 text

Monitor everything Alert appropriately Avoid alert fatigue

Slide 16

Slide 16 text

Efficiency ! ! ! Thoroughness

Slide 17

Slide 17 text

If I'd observed all the rules, I'd never have got anywhere. ! Marilyn Monroe

Slide 18

Slide 18 text

Every day I’m ETTOing

Slide 19

Slide 19 text

Why?

Slide 20

Slide 20 text

Trust and understanding

Slide 21

Slide 21 text

Don’t blame yourself

Slide 22

Slide 22 text

Blamelessness is more fun with friends

Slide 23

Slide 23 text

Practice makes perfect as close to perfect as we can hope for in a complex system based on reasonable expectations

Slide 24

Slide 24 text

Looking back, we should have eliminated hindsight

Slide 25

Slide 25 text

Could have, would have, should have

Slide 26

Slide 26 text

There is no root cause

Slide 27

Slide 27 text

Seek good remediation items

Slide 28

Slide 28 text

Process is an embedded reaction to prior stupidity ! Clay Shirky, Wikis, Grafitti, and Process

Slide 29

Slide 29 text

Communicate and advocate

Slide 30

Slide 30 text

etsy.me/justculture

Slide 31

Slide 31 text

Good luck