Jason Hand and I discuss the importance of moving away from a blame-oriented culture and towards a learning culture. Jason talks about the importance of understanding how cognitive biases influence decision-making and the need to understand this when conducting post mortems. Jason talks about balancing efficiency and thoroughness, and the importance of using blame-free post mortems as a means for learning. While Jason comes from a tech world, this talk has application to a variety of sectors, including high-risk industrial work.
Jason Hand’s Biography:
DevOps Evangelist at VictorOps, organizer of DevOpsDays - Rockies, author of the books O’Reilly’s “ChatOps: Managing Operations from Group Chat" as well as "ChatOps for Dummies”. Jason is a co-host of “Community Pulse” (a podcast on building community in tech), and organizer of a number of DevOps related events in the Denver/Boulder area.
A frequent speaker at DevOps events around the country, Jason enjoys talking to audiences large and small on a variety of technical and non-technical subjects such as Modern Incident Management, Learning From Failure, Cognitive Bias, ChatOps, and building communities.
Information Technology is no longer just a cost center and needs to be seen as a way for companies to innovate and become market leaders.
Trying to innovate and experiencing failure can be an important way to learn.
Post-Mortems are an important tool for learning and organizations should be transparent about learning and sharing that information about safety with others in the industry.
Root cause analysis may uncover something that broke, and that can be fixed, but it may result in a lack of innovation in complex systems unless the organization tries to avoid a check the box mentality for a quick-fix and actually learn and improve the system.
After negative events occur, when investigators use the word “why” that can sometimes imply “who” and it is important to avoid blame during post-mortem events, yet organizations often seek blame and accountability from a single individual.
Accountability means to “give an account of what took place” or describe what too place. Accountability is not the same as responsibility.
DevOps works to create high-functioning teams rather than silo’d teams. When silo’ing goes away organizations can become more innovative and other industries may learn a great deal from how DevOps is working to overcome silo’ing and a lack of cooperation towards system goals.
Theory of Constraints may be used tohelp understand system goals and reduce silos in organizations.
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Books: The Phoenix Project by Gene Kim, George Spafford, and Kevin Behr, Thinking Fast and Slow by Daniel Kahneman, Black Box Thinking by Matthew Syed and The Cynefin Mini-Book-Info-Q by Greg Brougham
Disruptive leadership podcast, safety podcast, leadership podcast, safety innovation podcast, high-reliability organizations podcast, human performance, human performance podcast, Crew Resource Management, Crew Resource Management Podcast, HRO podcast, DevOps, blame free post-mortem