Quick posting of older #paper notes I had, as I take a short paper-reading break for a few weeks: Can We Trust Best Practices? Six Cognitive Challenges of Evidence-Based Approaches by David D. Woods and Gary Klein.

https://www.researchgate.net/publication/300343833_Can_We_Trust_Best_Practices_Six_Cognitive_Challenges_of_Evidence-Based_Approaches

In which "best practices" are matched with 6 cognitive challenges and a suggestion to move from "best practices" to "better practices" to properly frame them as provisional.

Notes at https://ferd.ca/notes/paper-can-we-trust-best-practices.html & https://cohost.org/mononcqc/post/1942762-paper-can-we-trust

#ResilienceEngineering

Since last week I was at a conference where John Allspaw presented content from this paper, this week I decided to go and take a look in my notes for Richard Cook and Beth Adele Long's Building and revising adaptive capacity sharing for technical incident response: A case of resilience engineering, and put them in here.

This is one of the first papers in #ResilienceEngineering that moves from descriptiveness to practical applications in tech!

https://ferd.ca/notes/paper-building-and-revising-adaptive-capacity-sharing-for-technical-incident-response.html

Here's the full transcript of my QCon NYC 2023 talk on the #ResilienceEngineering track: Embrace Complexity; Tighten Your Feedback Loops.

https://ferd.ca/embrace-complexity-tighten-your-feedback-loops.html

Fetched and transferred my old notes on Richard Cook & David Wood's "Distancing Through Differencing" #paper https://www.researchgate.net/publication/292504703_Distancing_Through_Differencing_An_Obstacle_to_Organizational_Learning_Following_Accidents

In this one, they point that very local incident investigation reports and audiences who over-emphasize the differences between worksites can end up ignoring useful potential learnings that could apply to them, even in organizations with strong safety cultures

Notes at: https://cohost.org/mononcqc/post/1321331-paper-distancing-th

#LearningFromIncidents #ResilienceEngineering

This week's #paper is taking a look at Systemic Contributors Analysis and Diagram (SCAD), a #ResilienceEngineering approach that tries to go further than Root Cause Analysis by charting out the forces and pressures that create goal conflicts and encourage adaptive behavior often labelled "human error," where RCA stops.

See Multiple Systemic Contributors versus Root Cause: Learning from a NASA Near Miss by Katherine Walker: https://www.researchgate.net/publication/308194080_Multiple_Systemic_Contributors_versus_Root_Cause_Learning_from_a_NASA_Near_Miss

notes at: https://cohost.org/mononcqc/post/1300647-paper-systemic-cont

This week's #paper is "Nine Steps to Move Forward from Error" by Woods and Cook. It states 9 steps and 8 maxims (with 8 corollaries) to provide ways in which organizations and systems can constructively respond to failure, rather than getting stuck around concepts such as "human error."

https://www.researchgate.net/publication/226450254_Nine_Steps_to_Move_Forward_from_Error

It's a sort of quick overview of a lot of the content from both authors.

Notes at: https://cohost.org/mononcqc/post/1235221-paper-nine-steps-to

#ResilienceEngineering #LearningFromIncidents

A work discussion had me dig up my notes on one of my favorite texts On People and Computers in JCSs at Work, Chapter 11 of the book Joint Cognitive Systems: Patterns in Cognitive Systems Engineering by David Woods.

https://www.researchgate.net/publication/284173496_Chapter_11_On_People_and_Computers_in_JCSs_at_Work

It explains the concept of the "context gap" from #cybernetics and why humans and computers do balancing work in a joint alliance, rather than a strict separation of concerns.

Notes at https://cohost.org/mononcqc/post/1157774-paper-on-people-and

#LearningFromIncidents #ResilienceEngineering

The #resilienceEngineering @norootcause talks here about buckets 🪣 vs. tags 🏷️ for categorisation of incidents and favours tags to enabling creating bottom up theories on the fly.

You can smell the enchanting fragrance 🌸 of #groundedTheory approaches from cultural #anthropology here:

https://surfingcomplexity.blog/2023/02/19/good-category-bad-category-or-tag-dont-bucket/

And maybe I’m just retelling what everybody knows, but I rarely see those approaches and even rarer do I see the magic term grounded theory.

How do you all apply this method at work?

The #resilienceEngineering Lorin Hochstein talks here about buckets vs. tags for categorisation of incidents and favours tags to create a bottom up theory on the fly and if you take a deep slow breath you can smell the enchanting fragrance of #groundedTheory approaches from cultural #anthropology.

https://surfingcomplexity.blog/2023/02/19/good-category-bad-category-or-tag-dont-bucket/

I’d love to hear more from you my fellow engineers and/or tech anthropologists about how you create meaning and make sense out of what happened in your daily practices.

I spend so much time teaching folks how to learn from incidents and every day still face how much I still have to learn. That’s amazing. #ResilienceEngineering

Just a quick drop for some more notes on a key #paper in #ResilienceEngineering and Cognitive Systems Engineering: Klein & Woods' "Ten Challenges for Making Automation a "Team Player" in Joint Human-Agent Activity": https://www.researchgate.net/publication/3454232_Ten_Challenges_for_Making_Automation_a_Team_Player_in_Joint_Human-Agent_Activity

This paper is about the idea that automation should be considered a team player, and establishes a "basic compact" (what makes people work together) and exposes 10 challenges that must be met to do it decently.

Notes at: https://cohost.org/mononcqc/post/1119483-paper-ten-challenge

Re-posting some old notes I had on a #paper by Sidney Dekker: Failure to adapt or adaptations that fail: contrasting models on procedure and safety

https://lean-construction-gcs.storage.googleapis.com/wp-content/uploads/2022/11/18015945/D_DekkeronProcedures.pdf

The paper mentions that deviating from procedures can both be a source of errors, but also of success; preventing all deviance can be as risky as tolerating them all. It's a skill worth training in people, and a procedural gap to monitor.

Notes at https://cohost.org/mononcqc/post/1002599-paper-failure-to-ad

#LearningFromIncidents #ResilienceEngineering

Ended up writing about how we (@honeycombio) run incident response: dealing with the unknown, limited cognitive bandwidth, coordination patterns, psychological safety, and feeding information back into the organization.

https://thenewstack.io/how-we-manage-incident-response-at-honeycomb/

#SRE #ResilienceEngineering #LearningFromIncidents

This week's #paper: Richard Cook and Jans Rasmussen's "Going Solid": https://qualitysafety.bmj.com/content/qhc/14/2/130.full.pdf

The paper highlights properties of loosely-coupled systems saturating, then going tightly-coupled, and situating it within Rasmussen's Drift Model for accidents to frame the risks of hitting these points. It also suggests that better understanding of what your operating point is can help improve safety.

Notes at https://cohost.org/mononcqc/post/888958-paper-going-solid

#ResilienceEngineering #LearningFromIncidents

This week's #paper is titled "Rule- and role-retreat: An empirical study of procedures and resilience": https://www.researchgate.net/publication/50917226_Rule-_and_role_retreat_An_empirical_study_of_procedures_and_resilience

This is about how novel situations can have people fall back to established patterns. If things aren't working, follow the procedure harder!

We often assume that training means more knowledge of procedures. While useful, orgs must adapt to perturbations that challenge the established model of competence.

Notes at: https://cohost.org/mononcqc/post/806577-paper-rule-and-rol #ResilienceEngineering

I'm Rowland. I'm a software engineer with preferred focus on operations.

I like to learn in public, and I share what I learn on my website: https://row.land.

I'm interested in and would love to connect on:
#ResilienceEngineering
#WalkableCities
#CityDesign
#AppropriateTechnology
#Elixir
#SystemsThinking
#Japan
#Walking
#SoftwareDesign
#Antifragility

#introduction

I'm Rowland. I'm a software engineer with preferred focus on operations.

I like to learn in public, and I share what I learn on my website: https://row.land.

I'm interested in and would love to connect on:
#ResilienceEngineering
#WalkableCities
#CityDesign
#AppropriateTechnology
#Elixir
#SystemsThinking
#Japan
#Walking
#SoftwareDesign
#Antifragility

#introduction

Wrote a post about the Law of Stretched Systems, which states:

"Every system is stretched to operate at its capacity; as soon as there is some improvement ... it will be exploited to achieve a new intensity and tempo of activity"

And particularly about how it should also apply to our ability to deal with complexity, meaning that improving the understandability of a system never makes things easier for long:

https://ferd.ca/the-law-of-stretched-cognitive-systems.html

#ResilienceEngineering

As a cool follow-up for this, you may want to take a look at "Voice Loops as Coordination Aids in Space Shuttle Mission Control" by Emily S. Patterson and Jennifer Watts-Perotti: https://interruptions.net/literature/Patterson-CSCW-JCC99.pdf

It turns out NASA's voice loops come up all the time in #ResilienceEngineering and that #paper explains it rather well.

As usual, my (re-heated) cliff notes for it: https://cohost.org/mononcqc/post/539267-paper-voice-loops-a

#Paper of the week: Dr. Laura Maguire's Managing the Hidden Costs of Coordination: https://queue.acm.org/detail.cfm?id=3380779 -- a much shorter view into her thesis.

I posted my cliff notes at https://cohost.org/mononcqc/post/535665-paper-managing-the, but if you can read the paper, it's better, and if you can read the thesis, it's even better as well!

#ResilienceEngineering