AV ENGERS ASSEMBLE T HE T HANOS INCIDEN T
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@mattstratton
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SPOILER WARNINGS @mattstratton
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@mattstratton
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SO, WHAT HAPPENED? @mattstratton
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SO, WHAT HAPPENED? ▸ We will start by creating a post-mortem on the incident of “The Snap” ▸ Our approach will be the address this in a blameless fashion ▸ We want to understand what happened, as well as the process the Avengers used ▸ For purposes of this discussion, “The Avengers” will include characters not generally considered Avengers, please bear with me @mattstratton
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SO, WHAT HAPPENED? @mattstratton
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CONSTRUCT OUR TIMELINE ▸ Stick to the facts ▸ Include key decisions and actions taken by responders ▸ Avoid evaluating what should or shouldn’t have been done ▸ Start the timeline at a point before the incident began @mattstratton
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HIGH LEVEL TIMELINE ▸ Thanos obtains the Power Stone and the Space Stone ▸ Thor and the Guardians of the Galaxy decide to split up - Thor to head to Nidavellir with Rocket and Groot, the rest to head to Knowhere ▸ Thanos retrieves the Reality Stone from The Collector on Knowhere ▸ Dr. Strange uses the Time Stone to view millions of possible futures ▸ Thanos sacrifices Gamora on Vormir to obtain the Soul Stone ▸ Several team members attempt to recover the Infinity Gauntlet from Thanos on Titan @mattstratton
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HIGH LEVEL TIMELINE ▸ Dr. Strange decides to exchange the Time Stone for Tony Stark’s life ▸ Shuri works to remove the Mind Stone from Vision ▸ Various team members attempt to defend Vision in Wakenda ▸ Thanos obtains the Mind Stone from Vision ▸ Thor attacks Thanos but is unable to defeat him ▸ Thanos snaps his fingers, wiping out half of all life @mattstratton
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Groot Cause Analysis Credit to @djpiebob and @this_hits_home @mattstratton
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SYSTEMS ARE COMPLEX @mattstratton
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THERE IS NO SINGLE ROOT CAUSE OF MAJOR FAILURE IN COMPLEX SYSTEMS, BUT A COMBINATION OF CONTRIBUTING FACTORS THAT TOGETHER LEAD TO FAILURE @mattstratton
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Blameless @mattstratton
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WHY DOES BLAMELESSNESS MATTER? ▸ This impulse to blame and punish has the unintended effect of disincentivizing the knowledge sharing required to prevent future failure ▸ The goal of the postmortem is to understand what systemic factors led to the incident and identify actions that can help improve the resilience of the system ▸ Stay focused on how a mistake was made instead of who made it @mattstratton
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WHY IS BLAMELESSNESS HARD? ▸ When processing information, the human mind unconsciously takes shortcuts ▸ We are hard-wired from millions of years of evolutionary neurobiology to tend to blame ▸ The human mind optimizes for timeliness over accuracy, which is reinforced by cognitive biases @mattstratton
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@mattstratton
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COGNITIVE BIASES ▸ Fundamental attribution error ▸ Confirmation bias ▸ Hindsight bias ▸ Negativity bias @mattstratton
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FUNDAMENTAL ATTRIBUTION ERROR @mattstratton
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CONFIRMATION BIAS @mattstratton
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HINDSIGHT BIAS @mattstratton
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NEGATIVITY BIAS @mattstratton
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HOW TO AVOID BLAME
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ASK “WHAT” AND “HOW” QUESTIONS RATHER THAN “WHO” OR “WHY” @mattstratton
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CONSIDER MULTIPLE AND DIVERSE PERSPECTIVES @mattstratton
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ASK YOURSELF WHY A REASONABLE, RATIONAL, AND DECENT PERSON MAY HAVE TAKEN A PARTICULAR ACTION @mattstratton
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ABSTRACT TO AN INSPECIFIC RESPONDER @mattstratton
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CONTRAST WHAT YOU DID NOT INTEND WITH WHAT YOU DO INTEND @mattstratton
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ALL PRACTITIONER ACTIONS ARE ACTUALLY GAMBLES, THAT IS, ACTS THAT TAKE PLACE IN THE FACE OF UNCERTAIN OUTCOMES. Dr. Richard Cook @mattstratton
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YOU NEVER KNOW. YOU HOPE FOR THE BEST, THEN MAKE DO WITH WHAT YOU’VE GOT Nick Fury @mattstratton
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What can we learn? @mattstratton
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@mattstratton
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Have An Incident Commander @mattstratton
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DELEGATE AND COORDINATE @mattstratton
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DECISION MAKER @mattstratton
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SINGLE SOURCE OF TRUTH @mattstratton
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SHOULD NOT BE A RESPONDER @mattstratton
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Who should be the Incident Commander for the Avengers? @mattstratton
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Rotations Matter @mattstratton
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Escalate and Bring in Help @mattstratton
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Hero Culture @mattstratton
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Teamwork Makes the Dream Work @mattstratton
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SHARE ON-CALL ▸ Carol Danvers is the only one who carries a pager! ▸ The more folks on-call, the less the load for everyone ▸ Having a consistent mechanism for bringing in experts for incident response is key @mattstratton
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@mattstratton
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SO WHAT HAVE WE LEARNED? @mattstratton
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@mattstratton
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And perhaps most of all… @mattstratton
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@mattstratton
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https://speaking.mattstratton.com @mattstratton
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ACKNOWLEDGEMENTS ▸ Jeremy Meiss @IAmJerdog ▸ Karissa Peth @karissapeth ▸ Nell Shamrell-Harrington @nellshamrell ▸ Sarai Rosenberg @saraislet ▸ Ryan Kitchens @this_hits_home @mattstratton
