We have completed a postmortem on the incident and are instituting a number of controls to prevent similar incidents again. One of the core principles of reliable systems is that "Simply don't make mistakes" is not a viable strategy. Rather, you have to learn from mistakes.
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"Postmortem" is a term of art in the engineering community. Briefly, it is a formalized process which conducts a root cause analysis regarding the failure of a system to function as designed, identifying ways to improve the technical and human systems implicated.
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The engineering community is trending towards a norm of so-called blameless postmortems. Accountability is an interesting word; some institutions believe it is a synonym for "being found at fault" and therefore exists primarily outside of the building.
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Generally speaking, the engineering community uses the term to mean "the state of being a person specifically tasked with ensuring that the opportunities for improvement identified in a system are actually pursued an implemented."
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We will follow up tomorrow with the accountable team members to review progress on the remediations they are directly responsible for implementing or seeing implemented. We also discovered some opportunities for improvement in our incident management process.
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For example, we come from a variety of organizations, professional backgrounds, nations, and linguistic traditions. We were delayed during the incident process by failure to have meeting of the minds as to what imprecise words meant with respect to prioritization.
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An an example of cultural differences in engineering, I was informed by colleagues that I surprised them when, during the winddown of the incident response, I said "Statement of intent: I wish to stand down from the incident to travel to a medical appointment. Objections?"
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Some of my colleagues report being surprised that I would ask permission to do this, as someone who was not actively involved at that moment in the remediation.
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My view on the matter was different, and I didn't realize it until someone pointed it out: I came up in a particular engineering culture in Japan. In it, an executive leaving an ongoing incident while the engineers could not would be demonstrating catastrophically poor judgement
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So the executive followed the standard procedure on having private information regarding human life or safety: share information, clearly state intentions, wait for acknowledgement to act.
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I'm a big fan of the Five Whys, and I assume that you, at the intersection of engineering and Japanese culture, have an Opinion. Would love to see you tweet about it.
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