Inspired by Dr. Ivan Pupulidy's talk at #LFIConf23 about moving gracefully from compliance to learning. If you only talk about #RootCause when reviewing incidents you will likely miss opportunities to learn. What is normal? What is exceptional? How do experts know which one is at play? #LearningFromIncidents #WhiteboardBackground

Reviewing Woods' talk at #lficonf23. A lesson in pattern-centered inquiry at 10m7s (https://youtu.be/6Fl5KhCaGBs?t=607)
We did a study of a corpus of incidents. ... What is expertise in anesthesia? It wasn't a study of error. It was a study of expertise by looking at incidents. Our key finding was about anticipating bottlenecks ahead... and being prepared ahead of a potential crisis, even if the odds were low probability. If the crisis came when you were unprepared, it was already too late.

合氣道 Aikido for a Hijacked Retro https://lfi.wiki.dbbs.co/-aikido-for-a-hijacked-retro.html
These pages cover similar ground to the material I shared about aikido and incident facilitation at #LFIConf23 (it was in the incident stories track and therefore wasn't recorded).

You can never go wrong listening to @jessitron presentations and her talk at #LFIconf23 is no exception.

I particularly like the statement “Don’t take a technical task and make it into a social project”.

"Boundaries not uniformity" also strikes a cord with me. Diversity - including process diversity - helps find better ways and is less brittle.

https://www.youtube.com/watch?v=aI0VskmlEEg

Last week I was able to participate in the first ever Learning-From-Incident conference in Denver. It was amazing.
I also ticked off a big goal: Giving a public conference talk. https://youtu.be/LrK_1ePmz54 Nerve-wracking, but I'm glad I could share what we're doing.
#lficonf23 #LearningFromIncidents #CommunityOfPractice

Another gem from that talk,

"Don't take a technical task and turn it into a social project".

Couldn't agree more!

#LFIConf23

https://m.youtube.com/playlist?list=PLQmwzq_GIU-idCnJNR4t_aKb0HDCOXfZ1

#LFIConf23 the recordings for the inaugural Learning From Incidents conference are coming online 🤩

Video from #LFIConf23 is live!
(that was fast)

here's 15m on why we don't use templates for incident reviews

https://www.youtube.com/watch?v=aI0VskmlEEg

Oh hey. I talked at #LFIConf23 last week and the recording is now live!

I talk about how learning from incidents has shaped my role.

Reframing, advocacy, decision support…

https://youtu.be/ad1p69UmgPA

The talk I gave at #LFIConf23 is now online: https://youtu.be/6kY2YHKwhZ8

a couple choice slides about indeed’s incident analysis from #LFIConf23

this is what’s involved to take you beyond a template based incident review

From #LFIconf23 this week:

Simple and complicated systems yield to analysis.

Complex systems require sensemaking.

We do analysis (“exactly how does it work”) on programs and sense making (“what is going on here”) in software systems.

Both involve loops of inquiry.

OH: “I love [@jpaulreed’s] resting skeptic face!” #LFIConf23

Are there any schools or hospitals local to downtown Denver that could use #corsirosenthalbox ? We have 10 from #LFIConf23 to give away. We need them picked up by tonight or tomorrow morning.

Wise words from @PGSchuermann #LFIConf23

designing culture change is self-designing

because you can’t take anything off the shelf. You have to design the change in your culture.

Dr Ivan Pupulidy #LFIConf23

Great insight from
Laura Nolan: when we draw block diagrams of our systems, we invariably leave out the control links (e.g., monitoring). #LFIConf23

Getting #LFIConf23 FOMO 😔 would love a European LFIConf at some point

OH: “Yes, your organization subversion skills are legendary.”

#LFIConf23 #afterdark

advantages of LFI (qualitative) analysis:
1. neverending stream of samples.
2. Useful results right away
3. No useless arguments over causes and categories.
4. This stuff is fascinating!

@norootcause #LFIConf23

You look at this stuff, you get an understanding of reality and complex systems.