The Infinite Hows (or, the Dangers Of The Five Whys)

Posted 18 CommentsPosted in Cognitive Systems Engineering, Complex Systems, Culture, Human Factors, Resilience, Systems Safety

(this is also posted on O’Reilly’s Radar blog. Much thanks to Daniel Schauenberg, Morgan Evans, and Steven Shorrock for feedback on this) Before I begin this post, let me say that this is intended to be a critique of the Five Whys method, not a criticism of the people who are in favor of using […]

Translations Between Domains: David Woods

Posted 3 CommentsPosted in Cognitive Systems Engineering, Human Factors, Systems Safety

One of the reasons I’ve continued to be more and more interested in Human Factors and Safety Science is that I found myself without many answers to the questions I have had in my career. Questions surrounding how organizations work, how people think and work with computers, how decisions get made under uncertainty, and how […]

Counterfactual Thinking, Rules, and The Knight Capital Accident

Posted 14 CommentsPosted in Complex Systems, Human Factors, Systems Safety

In between reading copious amounts of indignation surrounding whatever is suboptimal about, you may or may not have noticed the SEC statement regarding the Knight Capital accident that took place in 2012. This Release No. 70694 is a document that contains many details about the accident, and you can read what looks like on the surface […]

Learning from Failure at Etsy

Posted 18 CommentsPosted in Cognitive Systems Engineering, Complex Systems, Culture, Etsy, Human Factors, Systems Safety

(This was originally posted on Code As Craft, Etsy’s engineering blog. I’m re-posting it here because it still resonates strongly as I prepare to teach a ‘postmortem facilitator’s course internally at Etsy.) Last week, Owen Thomas wrote a flattering article over at Business Insider on how we handle errors and mistakes at Etsy. I thought […]

A Mature Role for Automation: Part II

Posted 8 CommentsPosted in Cognitive Systems Engineering, Complex Systems, Human Factors

(Courtney Nash’s excellent post on this topic inadvertently pushed me to finally finish this – give it a read) In the last post on this topic, I hoped to lay the foundation for what a mature role for automation might look like in web operations, and bring considerations to the decision-making process involved with considering […]