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We deploy quite a lot
MTTR
MTTR>
MTBF
realtalk:things break
New View
Complex Socio-Technical Systems
Erkenntnis und Irrtum fließen aus denselben
psychischen Quellen; nur der Erfolg vermag beide
zu scheiden.— Ernst Mach, Erkenntnis und Irrtum (p. 116)
Things made sense at the time
People don't come to work to do a bad job
Nietzschean Anxiety
So I always get off the hook whatever I do?
There is a difference between explaining and
excusing human performance.
— Sidney Dekker, The Field Guide to Understanding Human Error (p. 196)
BlamelessPostmortems
Open Meeting
Everybody is Invited
Whathappened?
Timeline
Describe the pastDon't excuse it away
The Facilitator
Guide the Discussion
Look out for indicators of Old View
thinking
Counterfactuals
- she should have- if he would have- if they just had
- you failed to
Biases
Hindsight BiasConfirmation Bias
Outcome Bias
there are many more
Who is in charge?
Etsy School
Taught Facilitator Course
3 x 90 minutes
Remediation Items
incorporate learning and takeaway from
the meeting
turn surprises into known factors
MORGUE
https://github.com/etsy/morgue
Near Miss
Pre Mortem
"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."
ArchitectureReviews
OperabilityReviews
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
Investigate Success
Why did it work?
Human Error is where you stopped looking
peakscale.com/postmortems
codeascraft.com
etsy.com/codeascraft/talks
etsy.com/careers
Questions?
