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

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

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

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

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

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

This could never work in government.

”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

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