Learning From Failure & How You Can Too
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The document discusses learning from failures and improving as a learning organization. It introduces experts in the field and outlines frameworks for analyzing incidents, including distinguishing above-the-line and below-the-line perspectives. Key goals are increasing adaptability, enhancing expertise, advancing as a learning organization, and improving understanding of human factors and safety. Default practices for reviews are proposed, emphasizing questions over answers, learning surveys, and assigning ownership of action items. Challenges of the work are also noted.
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Learning From Failure & How You Can Too
- 1. N OV E M B E R 6 , 2 01 9 Chad Todd Learning From Failure & How You Can Too
- 2. Inspirational Cast of Characters John Allspaw Dr. Richard Cook Dr. David Woods
- 3. Incidents =
- 6. • Individual ‘mental models’ of the system below-the-line will go stale as change happens • Individuals will somehow need to construct enough understanding of how others understand components of the system in order to collaborate Challenges
- 7. Goals
- 8. Increase capacity to adapt to changes and surprises
- 9. Increase capacity to adapt to changes and surprises Enhance operational expertise
- 10. Increase capacity to adapt to changes and surprises Enhance operational expertise Advance as a learning organization
- 11. Increase capacity to adapt to changes and surprises Enhance operational expertise Advance as a learning organization Improve understanding of human factors and safety
- 12. Values
- 13. Deep conversations over shallow data
- 14. Adapting to new surprises over remediating prior incidents
- 15. Narrative descriptions of surprising events versus out-of-context quantitative data
- 16. How things went right versus why things went wrong
- 17. Blameless
- 18. Root Cause
- 19. Moving Beyond Human Error
- 20. “Why?” is the wrong question
- 22. escape from hindsight bias
- 23. understand the work performed at the sharp end of the system
- 24. search for systemic vulnerabilities
- 25. study how practice creates safety
- 26. search for underlying patterns
- 27. change will produce new failures
- 28. using new technology to support humans
- 30. stick to the timeline learning survey remediation brainstorm questions action items ownership
- 31. One of best ways to ensure you are following a path of exploration (instead of looking for a single fix) is by sticking closely to the timeline. stick to the timeline learning survey remediation brainstorm questions action items ownership
- 32. The power lies in the questions, not the answers. stick to the timeline learning survey remediation brainstorm questions action items ownership
- 33. Survey the group to ensure people are learning. stick to the timeline learning survey remediation brainstorm questions action items ownership
- 34. Anything goes, because we are looking for improvements to the current system and trying to unearth innovative ways to support the learnings from the meeting. stick to the timeline learning survey remediation brainstorm questions action items ownership
- 35. Not as important as the learning taking place, however, there will most likely be work that needs to be done. Keep in mind that new work brings on new complexities and more room for failures. stick to the timeline learning survey remediation brainstorm questions action items ownership
- 36. Decide who owns the action items and documentation stick to the timeline learning survey remediation brainstorm questions action items ownership
- 38. Invisible Parts of Expertise
- 39. Dumb Questions
- 41. Words/Phrases to Avoid jargon that’s not my job you should why always never only just
- 42. Words/Phrases to Seek what if could we how what what do you think about what would you have wanted to know
- 43. Pitfalls Counterfactual Reasoning Normative Language Mechanistic Reasoning Cherry Picking Data Shallow Data Gathering
- 44. What Makes a Good Facilitator
- 50. Unwanted Outcomes Positive Surprises Planned Outcomes What’s going on here?
- 51. Focus on what goes right
- 52. Challenges
- 53. Recap Remain Blameless Root Cause to Contributing Factors Ask The Right Questions Our Systems are Complex Focus On What's Going Right The Goal is to Learn
- 54. Incidents =
- 55. https://skybrary.aero/bookshelf/books/2928.pdf If it weren’t for the people… The Infinite Hows (or, the Dangers Of The Five Whys) https://www.kitchensoap.com/2014/11/14/the-infinite-hows-or-the-dangers-of-the-five-whys/ https://extfiles.etsy.com/DebriefingFacilitationGuide.pdf Etsy Debriefing Facilitation Guide Why Do Things Go Right http://www.safetydifferently.com/why-do-things-go-right/ How Complex Systems Fail http://web.mit.edu/2.75/resources/random/How%20Complex%20Systems%20Fail.pdf The STELLA Report https://snafucatchers.github.io/ Moving Past Shallow Incident Data https://www.adaptivecapacitylabs.com/blog/2018/03/23/moving-past-shallow-incident-data/