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devopsdays MSP 2018: Staying Alive

devopsdays MSP 2018: Staying Alive

Ronnie Chen

July 12, 2018
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  1. STAYING ALIVE PATTERNS FOR FAILURE MANAGEMENT FROM THE BOTTOM OF

    THE OCEAN 1 — devopsdays MSP 2018 @rondoftw
  2. TECHNICAL DIVING ▸ longer dive times ▸ deeper dives ▸

    overhead ceiling ▸ decompression obligations ▸ more gear. a lot more. ▸ higher pressure ▸ more risks 9 — devopsdays MSP 2018 @rondoftw
  3. RISKS MAY INCLUDE... 1. hypoxia 2. hyperoxia 3. nitrogen narcosis

    4. carbon dioxide buildup 5. oxygen sensor failure 6. deep tissue isobaric counterdiffusion (ICD) 7. high pressure nervous syndrome (HPNS) 8. exhausting your carbon dioxide scrubber 9. carbon dioxide channeling from a poorly packed scrubber 10. carbon buildup causing an spark leading to an oxygen fire. underwater. 11. flooding of breathing loop or circuitry 12. water mixing with the scrubbing agent to produce a toxic caustic soda that will give you chemical burns on your mouth, airway, and lungs 13. plain old decompression sickness 10 — devopsdays MSP 2018 @rondoftw
  4.   If you own a rebreather for five years, two

    percent of you are going to die on it. — Jill Heinerth, underwater explorer 11 — devopsdays MSP 2018 @rondoftw
  5. THIS IS A TALK ABOUT COMMUNICATION AND PROCESS ? ?

    ? 16 — devopsdays MSP 2018 @rondoftw
  6. BUT YOU'RE GETTING A MEANDERING MEDITATION ON BEST PRACTICES* WHEN

    DEALING WITH COMPLEX SYSTEMS INSTEAD * These guidelines have only been shown to work for life or death situations under the ocean. They have not been proven to work for tech. 19 — devopsdays MSP 2018 @rondoftw
  7. CATASTROPHES ARE CAUSED BY A FAILURE CASCADE ▸ you have

    a rebreather malfunction ▸ which you would have caught it if you were testing your equipment on a regular basis ▸ your backup tank had a leak and is running low and that wasn't caught either ▸ and your buddy is too far away and isn't checking in with you ▸ and your dive light that you use to communicate at a distance is out of power ▸ and in the excitement you kick up silt and the visibility drops ▸ and in your panic your air consumption goes up and then you breathe through the last of the air in your tank ▸ so you swim for the surface even though you have a decompression obligation 23 — devopsdays MSP 2018 @rondoftw
  8. A post-mortem that blames this incident on a simple mechanical

    malfunction would only cover 12.5% of the issues that led up to this accident. 24 — devopsdays MSP 2018 @rondoftw
  9. Complex system failures don't happen because a single part of

    the system fails. They happen because all the safety procedures that are supposed to stop the failure from cascading didn't work. 25 — devopsdays MSP 2018 @rondoftw
  10. CORE RULES OF SAFETY SYSTEMS 1. An unused safety system

    doesn't exist. 26 — devopsdays MSP 2018 @rondoftw
  11. NORMALIZATION OF DEVIANCE That natural human tendency, particularly in pressure

    circumstances, to take a safety shortcut. — Colonel Mike Mullane, astronaut 27 — devopsdays MSP 2018 @rondoftw
  12. FALSE FEEDBACK the absence of something bad happening means that

    it was safe ADAPTATION experience is no longer a suitable gauge of risk SOCIAL PRESSURE this is just how we do things 28 — devopsdays MSP 2018 @rondoftw
  13. CORE RULES OF SAFETY SYSTEMS 2. An untested safety system

    doesn't exist either! 29 — devopsdays MSP 2018 @rondoftw
  14. CORE RULES OF SAFETY SYSTEMS 3.Unused or untested safety systems

    are more dangerous than not having one at all. Therefore, safety systems must be tested at regular intervals. 30 — devopsdays MSP 2018 @rondoftw
  15. The length of this interval should be determined not only

    by how likely it is for this system to fail but also how great the impact will be if it does. 31 — devopsdays MSP 2018 @rondoftw
  16. A QUICK SIDENOTE ON ASSESSING RISK ▸ Make assessments based

    on likelihood of occurrence. ▸ Make assessments based on magnitude of regret. If you are only evaluating risk based on the chance of it happening, you must be prepared to experience the corresponding level of regret if it does. 32 — devopsdays MSP 2018 @rondoftw
  17. FAILURE MANAGEMENT ▸ A framework for resiliency ▸ The training

    and judgment to use it 35 — devopsdays MSP 2018 @rondoftw
  18. FAILURE MANAGEMENT FOR SYSTEMS ▸ Have redundancy for systems that

    you cannot survive without. ▸ Have a redundant pathway to success: a procedure for graceful degradation for systems that are important but not critical. ▸ Have a process for changing over from primary to redundant systems. 36 — devopsdays MSP 2018 @rondoftw
  19. FAILURE MANAGEMENT FOR SYSTEMS (CONT) ▸ Keep failures contained so

    that they don't bring down other systems ▸ Make it easy to do the right thing and hard to do the dangerous things 37 — devopsdays MSP 2018 @rondoftw
  20. TRAINING: INEXPERIENCED PEOPLE TO THE FRONT ▸ Most inexperienced person

    leads ▸ Experienced person advises, only intervening when necessary ▸ Team is invested in personal success to ensure mission success 40 — devopsdays MSP 2018 @rondoftw
  21. TRAINING: INEXPERIENCED PEOPLE TO THE FRONT (CONT) ▸ One of

    the best ways to equalize a gap in experience ▸ Opportunity to revise and improve problematic systems ▸ Help build good judgment 41 — devopsdays MSP 2018 @rondoftw
  22. GOOD JUDGMENT Good judgment enables the reshaping of rules and

    frameworks to adapt to a changing environment. 42 — devopsdays MSP 2018 @rondoftw
  23. REFINING JUDGMENT ▸ Post-Mortems ▸ Pre-Mortems ▸ Fire Drills ▸

    Revisit Past Decisions 43 — devopsdays MSP 2018 @rondoftw
  24. POST-MORTEMS ▸ Look at the safety procedures that failed to

    stop the cascade ▸ Look for opportunities to create new safety systems at critical points 44 — devopsdays MSP 2018 @rondoftw
  25. PRE-MORTEMS ▸ Don't wait for failures to build safety frameworks

    ▸ Identify potential avenues of of failure and make plans for them ▸ Include both likely failures and high regret failures 45 — devopsdays MSP 2018 @rondoftw
  26. FIRE DRILLS ▸ Vet your plans and safety systems ▸

    Perform targeted training ▸ Evaluate effectiveness of tools and documentation 46 — devopsdays MSP 2018 @rondoftw
  27. REVISIT PAST DECISIONS ▸ Examine successful operations to see what

    key insights were helpful ▸ Identify any dependency on luck in previous projects ▸ Share rationale for decisions 47 — devopsdays MSP 2018 @rondoftw
  28. I WANT TO LEARN MORE! 1. Richard I. Cook -

    How Complex Systems Fail 2. Astronaut Mike Mullane - https://www.youtube.com/watch?v=Ljzj9Msli5o 3. Steve Lewis aka decodoppler (Technical Diving Instructor) - Staying Alive 4. Sidney Dekker - Drift into Failure 5. Diane Vaughn - The Challenger Launch Decision 49 — devopsdays MSP 2018 @rondoftw