Multiple professional and research communities feel a profound loss at the death of Richard I. Cook. Richard died peacefully at home on August 31, 2022 in the loving care of his wife Karen and his family. Dr. Richard Cook was a polymath who excelled in multiple careers, usually simultaneously. A physician and anesthesiologist, he was […]
We have written before that documents written about an incident can take many forms and structures, depending on the author(s), purpose, and target audience. The goal of this post is to describe what makes public-facing articles that companies publish about incidents different from internal write-ups representing an effective incident analysis, and a rationale for why […]
Dr. Johan Bergström, who leads the MSc program in Human Factors and Systems Safety at Lund University (I am an alumnus) has a short ~7 minute video discussing three common analytical traps that incident analysts and accident investigators can get caught in. They are: 1. Counterfactual reasoning 2. Normative language 3. Mechanistic reasoning Have you seen any […]
These are just a few “Above-The-Line” patterns we’ve observed in cases over time, and potential nicknames for the patterns in the style of how cons are named in movies such as Ocean’s Eleven. Is this shorthand that we use in regular use in our work? Not regularly, but it’s been fun to name them once […]
I am an angel investor in Jeli.io, and could not be more excited for the product to come out of “stealth” mode, for many reasons! At its core, Jeli is built around the easy collection and annotation of this data, helping analysts make connections between chat transcripts, interviews, prior related incidents, and a whole host of […]
Demonstrating adaptability and the need for sustained adaptability Projections made in previous TT episode The projections made in Episode 2 are largely confirmed by experience during the summer. Private communications with individuals on these topics reveal substantial levels of stress and stress-related disturbances, notably sleep cycle disturbances, vivid dreaming, varying degrees of anhedonia, strained personal […]
A few weeks ago I gave a talk at the DevOps Enterprise Summit London (which was virtual). The description of the talk: In the past two years, we have had the opportunity to observe and explore the real nitty-gritty of how organizations handle, perceive, value, and treat the incidents that they experience. While the size, […]
I was honored to present a talk at the AllTheTalks conference a few weeks back. tl;dr: slides are here, video and transcript is below The topic was incident analysis (big surprise there!) and the notion of learning and fixing, and how these activities are related but not the same. A key idea here is that rather than focusing on simply focusing on […]
Operators and Organizations Coping with Prolonged and Stressful Emergencies We’ve made some observations over the past month about how tech organizations are adjusting their practices as a result of the COVID-19 pandemic. It’s still too early to synthesize these observations into what we might call “patterns” but some of them do appear to be taking […]
I was invited to give a talk at the Spotify office in New York last month on the topic of learning from incidents. Here is the first slide, which I hope to be the BLUF (“bottom line, up front”) of the talk… Here is the video recording of the talk, with an interactive transcription…