O11ycast - Ep. 59 - Learning From Incidents with Laura Maguire of Jeli

Line of representation (1:45) - STELLA report to look at the below the line (software) and above the line (human)

Learning from Incidents (7:50) - learning from safety practitioners and other industries (health care, aviation, etc.) on how to support work.

LFI Conference and site -

Safety Science (10:30) does have a current dichotomy of folks looking at how to support work (meaning adaptability to unexpected events and surprises) versus a more traditional preventative approach to avoid all accidents.

Recognizing we can’t prevent all accidents is hard.

And in the response how do we support people under time pressure, ambiguous data, etc. the information is not coming in at an orderly rate.

There is an over simplified comparison that it is learning from incidents vs single root cause analysis.

You have to accept your system is broken - it’s a question of when and where you’ll learn it’s broken.

15:44 - “it’s amazing how insidious that world view that .. systems are always performing optimally, and that humans are always performing optimally, and that the world is not full of surprise, and is not messy and unstructured. It’s amazing how prevalent that is”

16:25 - “My experience of working in this worlds is that no plan survives first contact with the environment in which you’re trying to execute it. The world is messy, and it’s unstructured, and problems are often difficult to see”

The importance of sharing and looking at how to improve responses

Dashboards and wiki pages can jokingly be referred to as gravestones - they exist or get updated only after issues or incidents occur.

O11ycast - Ep. 59, Learning From Incidents with Laura Maguire of Jeli