PostMortem Facilitation: Theory and Practice of "New View" Debriefings

Many organizations want to learn from failures. Postmortem debriefings and documents are a part of that learning process. However, leading a debriefing is not straightforward and done haphazardly can bring cultural and technical damage to an organization.

This 3-hour session will cover the theory and fundamentals of the “New View” on complex systems failure and “human error”, as well as techniques for facilitating an adverse event debriefing. Attendees should walk away with a more evolved sense of accident/outage investigation and a model to explore in their own organizations.

What will be covered

• Foundations and limitations of generating post-hoc narratives
• Fundamentals of the New View: accountability, responsibility, risk, and "safety"
• Debriefing techniques to facilitate dialogue with diverse perspectives and potential cognitive biases
• Plotting your exploration of dynamic fault management: the phases of anomaly response, communication, and diagnosis
• Interviewing tips and tricks: handling defensiveness and setting the stage for a productive and blame-free environment
• We will use case studies of known accidents and outages to discuss concepts
• How to think about the scope, purpose, and implementation of recommendations and remediation items

The session is intended to be very interactive, and sections will require back and forth with the attendees on the various topics

Background reading for attendees can be found here: http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.411.4985&rep=rep1&type=pdf