norootcause

norootcause, 11 months ago to random

If you claim the system failed because of human error, then you’re saying that your system requires error-free humans to function without failure.

If that’s the case, your problem isn’t the people, it’s that you have a fragile system.

norootcause, 11 months ago to random

> If I told you that US venture capitalists promoted a Ponzi scheme that used a cartoon computer game to steal hundreds of millions of dollars from poor workers in the Philippines and send it to North Korea to fund a ballistic missile program, you probably wouldn’t believe me. Unless I said “… using crypto,” in which case you would probably say “oh yeah that sounds about right.”

I wish I could write like Matt Levine.

norootcause, 11 months ago to random

New blog post: https://surfingcomplexity.blog/2023/06/26/active-knowledge/

norootcause, 3 months ago to random

Two of the biggest sources of incidents I’ve seen are:

1. Legacy code
2. Migrating away from legacy code

The conclusion is clear: you should only write non-legacy code

norootcause, 3 months ago to random

We should bring back cloaks. What a fantastic idea it is to treat a blanket as an article of clothing.

norootcause, 11 days ago to random

The hard thing about distributed systems is that "turn the whole thing off and on again" isn't an option.

norootcause, 5 months ago to random

"When systems or organizations don't work the way you think they should, it is generally not because the people in them are stupid or evil. It is because they are operating according to structures and incentives that aren't obvious from the outside." – Jennifer Pahlka, Recoding America.

https://www.recodingamerica.us/

norootcause, 2 months ago to random

Endlessly fascinated by goal conflicts and double binds.

"Workers coped with the double bind by developing a 'covert work system' that involved, as one worker put it, 'doing what the boss wanted, not what he said". – Woods et al., Behind Human Error

norootcause, 2 months ago to random

Resilience is about treating surprise as a first-class thing.

norootcause, 8 months ago to random

New blog post: https://surfingcomplexity.blog/2023/09/03/on-productivity-metrics-management-consultants/

norootcause, 2 months ago to random

New blog post: https://surfingcomplexity.blog/2024/03/26/the-problem-with-invariants-is-that-they-change-over-time/

norootcause, 2 months ago to random

In a complex system, there isn’t a “safety” knob that you can just turn to the right to increase safety. Safety features increase complexity (new failure modes!) and have opportunity costs (finite resources!). Every intervention involves a tradeoff.

norootcause, 2 months ago to random

Proposed org metric: reflection ratio:
(time spent on reflection) / (time spent on planning)

norootcause, 3 months ago to random

New blog post (book review): https://surfingcomplexity.blog/2024/02/11/book-review-trust-in-numbers/

norootcause, 2 months ago to random

"Human error is the attributed cause of large system accidents because human performance in these complex systems is so good. Failures of these systems are, by almost any measure, rare and unusual events. Most of the system operations go smoothly; incidents that occur do not usually lead to bad outcomes. These systems have come to be regarded as 'safe' by design rather than by control."

– R.I. Cook, D.D. Woods, Operating at the Sharp End: The Complexity of Human Error

norootcause, 5 days ago to random

New blog post: https://surfingcomplexity.blog/2024/05/25/the-error-term-isnt-pareto-distributed/

norootcause, 1 month ago to random

I think we should refer to an LLM as “Turing’s demon”.

norootcause, 1 month ago to random

You can’t win, but you’ve still gotta try

norootcause, 1 month ago to random

This Dijkstra quote feels timely:

“The question of whether a computer can think is no more interesting than the question of whether a submarine can swim.”

norootcause, 1 month ago to random

Whoever is responsible for redirecting https://wedontneedno.education to wikipedia: I salute you.

norootcause, 24 days ago to random

One of the most important skills is knowing where to direct your attention when you’re under load.

norootcause, 14 days ago to random

They should rename Chief Technology Officer to Chief Migration Officer.

norootcause, 2 months ago to random

"In general, outsiders pay attention to practitioners' coping strategies only after failure, when such processes seem awkward, flawed, and fallible. It is easy for post-incident evaluations to say that a human error occurred." – Woods et al., Behind Human Error

norootcause, 2 months ago to random

If you don’t know how the work actually gets done, your proposed improvements are unlikely to have the effects that you expect.

norootcause, 2 months ago to random

“Practitioners can only act on the knowledge they have.” –
D.D. Woods et al., Behind Human Error