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From YouTube: Lightning Talk: Whyhappn Instead of Whodunnit: Avoiding the Term “Human Error” - Silvia Pina

Description

Don’t miss out! Join us at our upcoming hybrid event: KubeCon + CloudNativeCon North America 2022 from October 24-28 in Detroit (and online!). Learn more at https://kubecon.io. The conference features presentations from developers and end users of Kubernetes, Prometheus, Envoy, and all of the other CNCF-hosted projects.

Lightning Talk: Whyhappn Instead of Whodunnit: Avoiding the Term “Human Error” - Silvia Pina, Independent

One of the keys to achieving reliable and secure systems is psychological safety, and this comes from having a truly blameless culture. In the past, I have encountered the term "human error" as the outcome of a "root cause analysis" process, and advocated within the company I was working for against its usage. This is the main motivator for proposing this talk. I would like also to gather some insights, from a systems thinking and organisational psychology standpoint, on how highly resilient organisations in different domains handle the human component of failures, as I think it is useful to have this perspective.

A

uh So uh the title of this talk is, then what happened instead of hutanit and I'm gonna talk about the reasons why you should avoid using the term human error, and you might think that everyone knows this by now, but quite recently, I came across a case where this term was used for classifying the reasons behind an incident. So this is a topic that is, that still needs to be talked about. So when we are doing this, we are like in a whodunit right.

A

It's like a negative christie story where we're trying to figure out who committed the crime in this case, who is responsible for the incident, and so this ties to an old view of human error that comes from a field where high reliability is a requirement, and this field is aviation. So, in the early days human error was considered the main cause for failures.

A

This is because the system or the machine is considered completely reliable and all safety issues come from the fact that humans are operating it. So humans are the weak link, but with time and with the progress in research around human factors in aviation, this old view gave way to a new view where a human error was no longer considered this the cause. It was rather the symptom of failure, uh and in this view, safety is not inherent in the system and progress is made by understanding how tasks environment and tools interact.

A

So we have a bit of progress when it comes to this to this new view.

A

But if we look at the full picture, when it comes to our performance in terms of interacting with complex systems and with an environment that has a huge amount of variability, then we know that this variability requires some level of adjustment and because this is the case, this is one of the reasons why we are successful.

A

It is also one of the reasons why there are failures, but failure here is then considered the flip side of success, and we no longer need to have human error as a category here in this new new view of human error. So it's more like a no view, and so what should we do?

A

Instead, I mean we could take away the focus from the individual and try to look at what organizations can do, and at this level it might be useful to consider some as a point of reference, some high reliability organizations and some of the principles that they will follow to ensure reliability.

A

And so they are enumerated here. So basically, these organizations are very uh preoccupied with failure and they will tend to try to as best identify all possible warning signs and to not to get to the point where there is a failure, so they will maintain a global view of all operations and when a failure does occur, then because they are committed to resilience, this failure is going to be a learning opportunity.

A

So we are going to see failure here as having a role in improving how these organizations work, and so we arrive at the conclusion of this talk, which is so.

A

We build resilience to failure uh by focusing on helping people to cope with complexity under pressure and keeping this sort of mindfulness or awareness at an organizational level, and so we move from this very human tendency to judge to a point where we can then understand why a failure happens, and this is why we need to no longer talk about human error in this context and if we take out the human like in this in this the human perspective like in this painting by makrit, I mean it's a free interpretation of the painting, uh then we can see that we will have a lot more to gain and the wider perspective, and this is all thank you.