Human Factors &
PostMortems
Daniel Schauenberg
[email protected]
@mrtazz
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We deploy quite a lot
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MTTR
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MTTR
>
MTBF
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realtalk:
things break
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New View
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Complex Socio-
Technical Systems
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Erkenntnis und Irrtum
fließen aus denselben
psychischen Quellen; nur
der Erfolg vermag beide
zu scheiden.
— Ernst Mach, Erkenntnis und Irrtum (p. 116)
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Things made sense at
the time
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People don't come to
work to do a bad job
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Nietzschean
Anxiety
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So I always get off the
hook whatever I do?
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There is a difference
between explaining and
excusing human
performance.
— Sidney Dekker, The Field Guide to Understanding
Human Error (p. 196)
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Blameless
Postmortems
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Open Meeting
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Everybody is Invited
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What
happened?
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Timeline
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Describe the past
Don't excuse it away
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The Facilitator
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Guide the Discussion
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Look out for
indicators of Old View
thinking
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Counterfactuals
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- she should have
- if he would have
- if they just had
- you failed to
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Biases
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Hindsight Bias
Confirmation Bias
Outcome Bias
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there are many
more
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Who is in
charge?
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Etsy School
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Taught Facilitator
Course
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3 x 90 minutes
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Remediation Items
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incorporate learning
and takeaway from
the meeting
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turn surprises into
known factors
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MORGUE
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https://github.com/
etsy/morgue
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Near Miss
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Pre Mortem
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"Hey all, I just ran rm -rf $DIR/
and since the variable was empty
I deleted my whole VM. This
would have been bad in
production. Don't do that."
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Architecture
Reviews
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Operability
Reviews
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It is also worth pointing
out that the bias towards
investigating failures
rather than success itself
represents a trade-off.
— Erik Hollnagel, The ETTO Principle: Efficiency-
Thoroughness Trade-Off