This document discusses the importance of learning from failures and mistakes. It notes that there is often pressure to quickly fix problems rather than take time to thoroughly understand the root causes. This can lead organizations to repeat the same mistakes. The document recommends using postmortems to carefully analyze incidents, identify root causes through questioning and multiple perspectives, and implement follow-up actions to prevent recurrences. It also suggests sharing postmortem findings more broadly to help others learn and using scenarios from postmortems for training.

1. Learning from Failure
Or failing to learn?
Bruno R. Zanuzzo
www.rzbruno.net

2. Workaround

4. Busyness

6. New Features = New Problems
Pressure to fix > learn: stacking up!

7. "How we act
depends
on how we understand
the situation we are in."
- The Ladder of Inference

8. We have different perspectives

9. Information
Reliability

12. Perception / inference: proved flawed

14. Hindsight bias: After it happen, it seems predictable.
1912
RMS Titanic
“If you feel like you knew it all along, it means
you won’t stop to examine why something really happened.”

15. Narrative fallacy: rationalization,
forced links between events

16. Confirmation
BIAS

17. Single Cause Fallacy (Reduction, Oversimplification)
Chronology:
1. New president elected;
2. After a month gas prices skyrocket;
Conclusion: It was his/her fault!

18. “I ‘confirm it’
I am in the
right path.”
Reinforce
Feedback
Loop

19. The Black Swan theory - Nicholas Nassim Taleb
No matter how much white swans people saw in the past,
you can’t assume all are white.
But one black swan is sufficient
to refute that assumption.
Our world is messy
and non-linear (disproportionate).

20. 2nd, 3rd order consequences,
a single key variable can take down an ecosystem

23. Yellowstone
National
Park

24. “Coral reefs
may be the
most diverse
ecosystem on
earth [..] may
be eradicate
In our lifespan.”

26. Coral
Reefs

30. 01h 15 minutes: a piece of ice the size of lower
Manhattan, 2 to 3 times higher, simply melted away

34. WHY:
Subjective explanation/opinion limited to
perception.
HOW:
Description of reality;
Sequence of events.

35. Multiple
perspectives
1. Thesis
2. Antithesis
3. Synthesis
Group
Interview

36. AF447: simulation shows: no human, no problem.
Black Box: Flight recorder

37. Postmortem

38. landing.google.com/sre/book.html

39. Postmortem?
Write; then ask Review (Questioning Exercise!)
> Written record of an incident;
> Its impact;
> The actions taken to mitigate or resolve it; (Timeline)
> The root cause(s);
> The follow-up actions to prevent the incident from recurring.

40. Making others aware.
You’ll build up themes overtime,
Keep it easy to track.

41. Replay postmortem scenarios as training
[...]
What
would
you do?
Ask the
boss?
Don’t forget the
audience!

43. Bruno R. Zanuzzo
www.rzbruno.net