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<h1 class="mb-4 text-break">Incident Analysis: How *Learning* is Different Than *Fixing*</h1>
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<p>I presented this at the excellent AllTheTalks Conference during the COVID-19 pandemic. :/</p>
<p>What does it mean to actually "learn" from an incident? </p>
<p>This talk will describe what we can do differently in the industry on this front, based on foundational methods from Cognitive Systems Engineering, Human Factors, and Resilience Engineering.</p>
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April 15, 2020
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<div id="transcript" class="container py-4 transcript text-break">
<h2 class="mb-4">Transcript</h2>
<ol>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Incident Analysis: How Learning Is Different Th..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_0.jpg">Incident Analysis: How Learning Is Different Than Fixing John Allspaw</a>
</h3>
Adaptive Capacity Labs
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* The Main Gist • Current and typical approaches ..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_1.jpg">The Main Gist • Current and typical approaches to “learning</a>
</h3>
from incidents” have very little to do with actual learning. • Learning is not the same as fixing • Most post-incident review documents are written to be filed, not written to be read. • Changing the primary focus from fixing to learning will result in a significant competitive advantage
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* When you focus on fixing things, they tend to ge..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_2.jpg">When you focus on fixing things, they tend to get</a>
</h3>
fixed quickly, with the materials and methods at hand. The quality and effectiveness of the fixing — and preventing future issues — is proportional to how well you understand how the thing works.
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* attention paid to learning will always yield hi..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_3.jpg">attention paid to learning will always yield higher-quality fixing focusing</a>
</h3>
exclusively on fixing is a barrier for learning
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Tendency is to think the only/greatest value is..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_4.jpg">Tendency is to think the only/greatest value is here Conventional</a>
</h3>
View on Where Post-Incident Analysis Has Value incident happens… (maybe) someone preps a timeline… a postmortem meeting, where (maybe) you fill out some template… (maybe) someone compiles a report… ACTION ITEMS FINALLY! very expensive meeting
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* On “learning” • Learning is happening all of th..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_5.jpg">On “learning” • Learning is happening all of the time,</a>
</h3>
it’s a core part of being human. • What is learned, who learns, when they learn, and how they learn depends on how well practices are set up to support it. • No one can understand everything about everything. We should be surprised that things work as well as they do, given this! • Frequency of incidents has nothing to do with how well an organization learns! (see first bullet) It may be a signal about what they’re learning.
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Conventional Myth A canonical set of “lessons” ..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_6.jpg">Conventional Myth A canonical set of “lessons” can be extracted</a>
</h3>
from an incident, which is then “shared” to a group. Reality Different people will have varying understandings before and after an incident, and what mysteries remain for them cannot be captured or addressed in a “one size fits all” package. The perceived problem to be solved, then, is to somehow “share” better. * we tend to say “share” when typically we mean “make available to others” What is important/notable/interesting will differ from person to person. what they actually remember!
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* if you can’t remember something, you can’t say ..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_7.jpg">if you can’t remember something, you can’t say you’ve learned</a>
</h3>
it
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<a class="text-muted font-italic" href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_8.jpg">None</a>
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* when we ask people about incidents • they becom..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_9.jpg">when we ask people about incidents • they become animated</a>
</h3>
when they tell the story • they include elements of suspense in the structure of how they tell it • they include elements of surprise (“what we didn’t know at the time was…”) • they set some context (“now remember, this is the day we did our IPO…”) • they recall it in detail even if it’s many years since
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* stories that you remember have elements of chal..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_10.jpg">stories that you remember have elements of challenge, struggle, and</a>
</h3>
difficulty.
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Interesting incident analysis documents get rea..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_11.jpg">Interesting incident analysis documents get read. Compelling incident analysis documents</a>
</h3>
get read and shared with others. Uninteresting documents…don’t. Fascinating documents get read, shared with others, commented on, asked about, referenced in code comments, …in pull requests, …in architecture diagrams, …in other incident writeups, …in newhire onboarding, … This film was made available in thousands of theaters around the world.
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Make Effort to Highlight The Messy Details • Wh..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_12.jpg">Make Effort to Highlight The Messy Details • What was</a>
</h3>
difficult for people to understand during the incident? • What was surprising for people about the incident? • How do people understand the origins of the incident? • What mysteries still remain for people?
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* I want to know what was difficult about this, an..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_13.jpg">I want to know what was difficult about this, and</a>
</h3>
I want to be able to ask questions about that.
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Flip from “severity” to difficulty • “Customer i..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_14.jpg">Flip from “severity” to difficulty • “Customer impact” is not</a>
</h3>
equivalent to the difficulty of solving the issue. • Multiple difficulties can exist in the same incident. • Fielding questions about what was — or still is — difficult is how critical understandings are spread and how lasting memories are formed.
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* “this is how it all works” “this is how it all ..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_15.jpg">“this is how it all works” “this is how it</a>
</h3>
all works” “this is how it all works” “this is how it all works” “this is how it all works”
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* “this is how it all works” “this is how it all ..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_16.jpg">“this is how it all works” “this is how it</a>
</h3>
all works” “this is how it all works” “this is how it all works” “this is how it all works”
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* “this is how it all works” “this is how it all ..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_17.jpg">“this is how it all works” “this is how it</a>
</h3>
all works” “this is how it all works” “this is how it all works” “this is how it all works”
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* “oh…I thought it did X nightly, not weekly…” “w..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_18.jpg">“oh…I thought it did X nightly, not weekly…” “wait -</a>
</h3>
I thought everyone knew that Y was an issue… only I knew that?” “I knew about N but didn’t know how it got to be that way…” “ok, got it - A feeds B, but C also feeds B…” “I didn’t know M could break silently like that…”
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Fine Goals For A Post-Incident Meeting …when pa..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_19.jpg">Fine Goals For A Post-Incident Meeting …when participants in a</a>
</h3>
post-incident group meeting leave the meeting knowing: a. new things they didn’t know when they entered the meeting b. new things they didn’t know about what their colleagues know c. how to continue discussions and where to capture it
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Fine Goals For A Post-Incident Review Writeup …..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_20.jpg">Fine Goals For A Post-Incident Review Writeup …when readers of</a>
</h3>
a post-incident review writeup are finished reading, they know: a. new things they didn’t know when they started reading b. new things they didn’t know about what their colleagues know c. how to continue discussions and where to capture it
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Some things to experiment with" href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_21.jpg">Some things to experiment with</a>
</h3>
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* • Separate the generation of “follow-up” items ..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_22.jpg">• Separate the generation of “follow-up” items from a group</a>
</h3>
incident review meeting • Record in the document who responded to the incident, and who attended the group meeting • Capture things that were done after the incident but before the group meeting in the document • Give write-ups to brand new engineers and ask them to record any and all questions they have after reading it • Link company-specific jargon/terms to documents that describe them • Ask more people to draw diagrams in debriefings and include them in the writeup
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* “If the incident analyst participated in the in..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_23.jpg">“If the incident analyst participated in the incident, they will</a>
</h3>
inevitably have a deeper understanding and bias towards the incident that will be impossible to remove in the process of analysis.” Ryan Kitchens https://www.learningfromincidents.io/blog/ Have someone who was not involved in the event lead the analysis.
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* “The cliche idea that we would do this work to ..." href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_24.jpg">“The cliche idea that we would do this work to</a>
</h3>
reduce the number of incidents or to lessen the time to remediate is too simplistic. Of course organizations want to have fewer incidents, however stating this as an end goal actually hurts our organizations. Indeed, it will lead to a reduction in incident count–not from actually reducing the number of incidents, but rather lessening how and how often they are reported.” Ryan Kitchens https://www.learningfromincidents.io/blog/ Resist focusing on reducing the number of incidents. Focus instead on increasing the number of people who want to read reports and attend the PIR meetings.
</div>
</li>
<li class="mb-2">
<div class="slide-transcript">
<h3 class="fs-6 fw-normal">
<a title="Incident Analysis: How *Learning* is Different Than *Fixing* Thank You!" href="https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/slide_25.jpg">Thank You!</a>
</h3>
</div>
</li>
</ol>
</div>
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{"@context":"https://schema.org","@type":"PresentationDigitalDocument","name":"Incident Analysis: How *Learning* is Different Than *Fixing*","description":"I presented this at the excellent AllTheTalks Conference during the COVID-19 pandemic. :/\r\n\r\nWhat does it mean to actually \"learn\" from an incident? \r\n\r\nThis talk will describe what we can do differently in the industry on this front, based on foundational methods from Cognitive Systems Engineering, Human Factors, and Resilience Engineering.","url":"https://speakerdeck.com/jallspaw/incident-analysis-how-star-learning-star-is-different-than-star-fixing-star","encodingFormat":"application/pdf","author":{"@type":"Person","name":"John Allspaw","url":"https://speakerdeck.com/jallspaw"},"thumbnailUrl":"https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/preview_slide_0.jpg?15292120","educationalUse":"presentation","inLanguage":"en","keywords":"Technology","datePublished":"2020-04-15","dateModified":"2020-04-16","associatedMedia":{"@type":"MediaObject","contentUrl":"https://files.speakerdeck.com/presentations/bb9960d3829e42319d7234a05793c221/AllTheTalks_2020.pdf","encodingFormat":"application/pdf"},"interactionStatistic":[{"@type":"InteractionCounter","interactionType":{"@type":"WatchAction"},"userInteractionCount":5281},{"@type":"InteractionCounter","interactionType":{"@type":"LikeAction"},"userInteractionCount":3}],"hasPart":[{"@type":"CreativeWork","position":1,"text":"Incident Analysis:\nHow Learning Is Different Than Fixing\nJohn Allspaw\nAdaptive Capacity Labs\n\f"},{"@type":"CreativeWork","position":2,"text":"The Main Gist\n• Current and typical approaches to “learning from incidents” have very little\nto do with actual learning.\n• Learning is not the same as fixing\n• Most post-incident review documents are written to be filed, not written\nto be read.\n• Changing the primary focus from fixing to learning will result in a\nsignificant competitive advantage\n\f"},{"@type":"CreativeWork","position":3,"text":"When you focus on fixing things,\nthey tend to get fixed quickly, with\nthe materials and methods at hand.\nThe quality and effectiveness of the fixing\n— and preventing future issues — is\nproportional to how well you understand\nhow the thing works.\n\f"},{"@type":"CreativeWork","position":4,"text":"attention paid to learning will\nalways yield higher-quality fixing\nfocusing exclusively on fixing is a\nbarrier for learning\n\f"},{"@type":"CreativeWork","position":5,"text":"Tendency is to think the only/greatest\nvalue is here\nConventional View on Where Post-Incident Analysis Has Value\nincident\nhappens…\n\n(maybe)\nsomeone\npreps a timeline…\na postmortem\nmeeting, where (maybe)\nyou fill out some template…\n(maybe)\nsomeone\ncompiles a report…\nACTION\nITEMS\nFINALLY!\nvery expensive meeting\n\f"},{"@type":"CreativeWork","position":6,"text":"On “learning”\n• Learning is happening all of the time, it’s a core part of being human.\n• What is learned, who learns, when they learn, and how they learn depends\non how well practices are set up to support it.\n• No one can understand everything about everything. We should be\nsurprised that things work as well as they do, given this!\n• Frequency of incidents has nothing to do with how well an organization\nlearns! (see first bullet) It may be a signal about what they’re learning.\n\f"},{"@type":"CreativeWork","position":7,"text":"Conventional Myth\nA canonical set of “lessons” can be extracted from an\nincident, which is then “shared” to a group.\nReality\nDifferent people will have varying understandings\nbefore and after an incident, and what mysteries\nremain for them cannot be captured or addressed in\na “one size fits all” package.\nThe perceived problem to be solved, then, is to\nsomehow “share” better.\n* we tend to say “share” when typically we mean “make available to others”\nWhat is important/notable/interesting will differ from\nperson to person.\nwhat they actually remember!\n\f"},{"@type":"CreativeWork","position":8,"text":"if you can’t remember something,\nyou can’t say you’ve learned it\n\f"},{"@type":"CreativeWork","position":10,"text":"when we ask people about incidents\n• they become animated when they tell the story\n• they include elements of suspense in the structure of how they tell it\n• they include elements of surprise (“what we didn’t know at the time was…”)\n• they set some context (“now remember, this is the day we did our IPO…”)\n• they recall it in detail even if it’s many years since\n\f"},{"@type":"CreativeWork","position":11,"text":"stories that you remember have\nelements of challenge, struggle, and\ndifficulty.\n\f"},{"@type":"CreativeWork","position":12,"text":"Interesting incident analysis documents get read.\nCompelling incident analysis documents get read and shared with others.\nUninteresting documents…don’t.\nFascinating documents get read, shared with others,\ncommented on, asked about, referenced in code comments,\n…in pull requests,\n\n…in architecture diagrams,\n\n…in other incident writeups,\n\n…in newhire onboarding,\n\n…\nThis film was made available in\nthousands of theaters around the\nworld.\n\f"},{"@type":"CreativeWork","position":13,"text":"Make Effort to Highlight The Messy Details\n• What was difficult for people to understand during the incident?\n• What was surprising for people about the incident?\n• How do people understand the origins of the incident?\n• What mysteries still remain for people?\n\f"},{"@type":"CreativeWork","position":14,"text":"I want to know what was difficult\nabout this, and I want to be able to\nask questions about that.\n\f"},{"@type":"CreativeWork","position":15,"text":"Flip from “severity” to difficulty\n• “Customer impact” is not equivalent to the difficulty of solving the issue.\n• Multiple difficulties can exist in the same incident.\n• Fielding questions about what was — or still is — difficult is how critical\nunderstandings are spread and how lasting memories are formed.\n\f"},{"@type":"CreativeWork","position":16,"text":"“this is how it\nall works”\n“this is how it\nall works”\n“this is how it\nall works”\n“this is how it\nall works”\n“this is how it\nall works”\n\f"},{"@type":"CreativeWork","position":17,"text":"“this is how it\nall works”\n“this is how it\nall works”\n“this is how it\nall works”\n“this is how it\nall works”\n“this is how it\nall works”\n\f"},{"@type":"CreativeWork","position":18,"text":"“this is how it\nall works”\n“this is how it\nall works”\n“this is how it\nall works”\n“this is how it\nall works”\n“this is how it\nall works”\n\f"},{"@type":"CreativeWork","position":19,"text":"“oh…I thought it\ndid X nightly,\nnot weekly…”\n“wait - I thought everyone\nknew that Y was an issue…\nonly I knew that?”\n“I knew about N but\ndidn’t know how it got\nto be that way…”\n“ok, got it - A feeds B,\nbut C also feeds B…”\n“I didn’t know M\ncould break silently\nlike that…”\n\f"},{"@type":"CreativeWork","position":20,"text":"Fine Goals For A Post-Incident Meeting\n…when participants in a post-incident group meeting leave the meeting\nknowing:\na. new things they didn’t know when they entered the meeting\nb. new things they didn’t know about what their colleagues know\nc. how to continue discussions and where to capture it\n\f"},{"@type":"CreativeWork","position":21,"text":"Fine Goals For A Post-Incident Review Writeup\n…when readers of a post-incident review writeup are finished reading, they\nknow:\na. new things they didn’t know when they started reading\nb. new things they didn’t know about what their colleagues know\nc. how to continue discussions and where to capture it\n\f"},{"@type":"CreativeWork","position":22,"text":"Some things to\nexperiment with\n\f"},{"@type":"CreativeWork","position":23,"text":"• Separate the generation of “follow-up” items from a group incident review meeting\n• Record in the document who responded to the incident, and who attended the\ngroup meeting\n• Capture things that were done after the incident but before the group meeting in the\ndocument\n• Give write-ups to brand new engineers and ask them to record any and all\nquestions they have after reading it\n• Link company-specific jargon/terms to documents that describe them\n• Ask more people to draw diagrams in debriefings and include them in the writeup\n\f"},{"@type":"CreativeWork","position":24,"text":"“If the incident analyst\nparticipated in the incident, they\nwill inevitably have a deeper\nunderstanding and bias towards\nthe incident that will be\nimpossible to remove in the\nprocess of analysis.”\nRyan Kitchens\nhttps://www.learningfromincidents.io/blog/\nHave someone who was\nnot involved in the event\nlead the analysis.\n\f"},{"@type":"CreativeWork","position":25,"text":"“The cliche idea that we would do this work to\nreduce the number of incidents or to lessen\nthe time to remediate is too simplistic.\nOf course organizations want to have fewer\nincidents, however stating this as an end goal\nactually hurts our organizations. Indeed, it will\nlead to a reduction in incident count–not from\nactually reducing the number of incidents, but\nrather lessening how and how often they are\nreported.”\nRyan Kitchens\nhttps://www.learningfromincidents.io/blog/\nResist focusing on\nreducing the number of\nincidents.\nFocus instead on\nincreasing the number\nof people who want to\nread reports and attend\nthe PIR meetings.\n\f"},{"@type":"CreativeWork","position":26,"text":"Thank You!\n\f"}],"accessibilityFeature":["transcript"]}
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