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ESCALA TION And RESPONSE Out age scenarios John Allspa w - PowerPoint PPT Presentation

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ESCALA TION And RESPONSE Out age scenarios John Allspa w Wednesday, April 24, 13 Wednesday, April 24, 13 TROUBLESHOOTING This is NOT about troubleshooting Or, not just about troubleshooting Wednesday, April 24, 13 Wednesday, April 24,

  1. ESCALA TION And RESPONSE Out age scenarios John Allspa w Wednesday, April 24, 13

  2. Wednesday, April 24, 13

  3. TROUBLESHOOTING This is NOT about troubleshooting Or, not just about troubleshooting Wednesday, April 24, 13

  4. Wednesday, April 24, 13

  5. • HROs • Decision Making • Communication • Team Coordination • A little bit of psychology Wednesday, April 24, 13

  6. Wednesday, April 24, 13

  7. Wednesday, April 24, 13

  8. How important is this? Wednesday, April 24, 13

  9. Amazon.com Github.com Etsy.com Google JP Morgan Heroku Bank of America Wednesday, April 24, 13

  10. Wednesday, April 24, 13

  11. Where to learn from? Wednesday, April 24, 13

  12. TMI Wednesday, April 24, 13

  13. Wednesday, April 24, 13

  14. Wednesday, April 24, 13

  15. Dr. Richard Cook, Velocity US 2012 http://www.youtube.com/watch?v=R_PDc0HFdP0 Wednesday, April 24, 13

  16. “The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea” Rochlin, La Porte, and Roberts. Naval War College Review 1987 http://govleaders.org/reliability.htm Wednesday, April 24, 13

  17. High Reliability Organizations Wednesday, April 24, 13

  18. Wednesday, April 24, 13

  19. What Goes On? Wednesday, April 24, 13

  20. Jens Rasmussen, 1983 Senior Member, IEEE “Skills, Rules, and Knowledge; Signals, Signs, and Symbols, and Other Distinctions in Human Performance Models” IEEE Transactions On Systems, Man, and Cybernetics, May 1983 Wednesday, April 24, 13

  21. SKILL - BASED Simple, routine RULE - BASED Knowable, but unfamiliar KNOWLEDGE - BASED WTF IS GOING ON? Wednesday, April 24, 13

  22. OODA Loop Observe Orient Decide Act Planning Metrics Execution Analysis Resourcing Monitoring Visualization Alerting Correlation Alarming credit: http://blog.b3k.us/ooda.html Wednesday, April 24, 13

  23. Characteristics of response to escalating scenarios Wednesday, April 24, 13

  24. Characteristics of response to escalating scenarios ...tend to neglect how processes develop within time (awareness of rates) versus assessing how things are in the moment “On the Difficulties People Have in Dealing With Complexity” Dietrich Doerner, 1980 Wednesday, April 24, 13

  25. Characteristics of response to escalating scenarios ...have di ffi culty in dealing with exponential developments (hard to imagine how fast something can change, or accelerate) “On the Difficulties People Have in Dealing With Complexity” Dietrich Doerner, 1980 Wednesday, April 24, 13

  26. Characteristics of response to escalating scenarios ...inclined to think in causal SERIES, instead of causal NETS. A therefore B, instead of A, therefore B and C (therefore D and E), etc. “On the Difficulties People Have in Dealing With Complexity” Dietrich Doerner, 1980 Wednesday, April 24, 13

  27. PITFALLS Thematic Vagabonding Wednesday, April 24, 13

  28. PITFALLS Goal Fixation Wednesday, April 24, 13

  29. PITFALLS Heroism Non-communicating lone wolf-isms Wednesday, April 24, 13

  30. Wednesday, April 24, 13

  31. TEAMS • Divide and conquer applied to problem space, division of labor • Incident resolution vs. Problem resolution • Reproducibility • Fault Tolerance E ff ects Wednesday, April 24, 13

  32. TEAMS Shotgun debugging Wednesday, April 24, 13

  33. JOINT ACTIVITY • Interpredictability • Common Ground • Directability http://csel.eng.ohio-state.edu/woods/distributed/CG%20final.pdf Wednesday, April 24, 13

  34. Interpredictability Wednesday, April 24, 13

  35. Common Ground Wednesday, April 24, 13

  36. Directability Wednesday, April 24, 13

  37. Improvisation Wednesday, April 24, 13

  38. IMPROVISATION Wednesday, April 24, 13

  39. IMPROVISATION Wednesday, April 24, 13

  40. Improvisation “...you can’t improvise on nothing; you got to improvise on something.” Charles Mingus Wednesday, April 24, 13

  41. Diagnose the problem Represent the problem A p p l y Detect the Generate a L e v e r a g e course of Problem/Opportunity P o i n t s action Evaluate Wednesday, April 24, 13

  42. Communication • Explicitness • Timing • Assertiveness Wednesday, April 24, 13

  43. Communication Passive Assertive Aggressive (be here) Wednesday, April 24, 13

  44. Wednesday, April 24, 13

  45. Communication • IRC? • Face-To-Face? • Conference Call? • Morse Code? Wednesday, April 24, 13

  46. Transmission Encode Decode Meaning Meaning Sender Receiver Wednesday, April 24, 13

  47. Transmission Encode Decode Meaning Meaning Sender Receiver Meaning Meaning Receiver Sender Decode Encode Transmission Wednesday, April 24, 13

  48. Feedback Informational Wednesday, April 24, 13

  49. Feedback Corrective Wednesday, April 24, 13

  50. Feedback Reinforcing Wednesday, April 24, 13

  51. Decision Making Naturalistic Decision Making (NDM) Gary Klein Wednesday, April 24, 13

  52. Decision Making Step One: What is the problem? Wednesday, April 24, 13

  53. Decision Making Step Two: What shall I do? Wednesday, April 24, 13

  54. Decision Making Recognition-Primed Decisions Wednesday, April 24, 13

  55. Decision Making Rule-Based Decisions Wednesday, April 24, 13

  56. Decision Making Choice decisions Wednesday, April 24, 13

  57. Decision Making Creative decisions Wednesday, April 24, 13

  58. Decision Making Decreasing cognitive effort Decreasing effects of stress Creative Choice Rule-Based RPD Increasing cognitive effort Increasing effects of stress Wednesday, April 24, 13

  59. PRE-Mortems Wednesday, April 24, 13

  60. POST Mortems http://codeascraft.etsy.com/2012/05/22/blameless-postmortems/ Wednesday, April 24, 13

  61. Controls Wednesday, April 24, 13

  62. “Human Error” • An attribution AFTER the fact • A symptom, not a cause • “Root” cause? • Useless labeling • Using the term is the largest indicator that learning is not your goal Wednesday, April 24, 13

  63. Mature Role of Automation “Ironies of Automation” - Lisanne Bainbridge http://www.bainbrdg.demon.co.uk/Papers/Ironies.html Wednesday, April 24, 13

  64. Mature Role of Automation • Moves humans from manual operator to supervisor • Extends and augments human abilities, doesn’t replace it • Doesn’t remove “human error” • Are brittle • Recognize that there is always discretionary space for humans • Recognizes the Law of Stretched Systems Wednesday, April 24, 13

  65. Law of Stretched Systems • Moves humans from manual operator to supervisor • Extends and augments human abilities, doesn’t replaRecognizes the Law of Stretched Systems Wednesday, April 24, 13

  66. Law of Stretched Systems “Every system is stretched to operate at its capacity; as soon as there is some improvement, for example, in the form of new technology, it will be exploited to achieve a new intensity and tempo of activity” D. Woods, E. Hollnagel, “Joint Cognitive Systems: Patterns” 2006 Wednesday, April 24, 13

  67. SUMMARY Wednesday, April 24, 13

  68. “In preparing for battle, I have always found that plans are useless but planning is indispensable.” - Eisenhower Wednesday, April 24, 13

  69. So what can we do? We develop our Non-Technical Skills • Communication • Decision Making • Improvisation Wednesday, April 24, 13

  70. So what can we do? We tailor our environment to adapt • Learning from outages (PostMortem) • Anticipating problems (PreMortem) • Gather Meta-Metrics Wednesday, April 24, 13

  71. Wednesday, April 24, 13

  72. THE END Wednesday, April 24, 13

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