Also the classic Field Guide to Understanding Human Error.

Amazon: https://www.amazon.com/Field-Guide-Understanding-Human-Error...

Older PDF (paperback is well worth it, in my opinion): http://www.leonardo-in-flight.nl/PDF/FieldGuide%20to%20Human...

The path to a disaster has been compared to a tunnel [0]. You can escape from the tunnel at many points, but you may not realize it.

Trying to find the 'real cause' is a fool's errand, because there are many places and ways to avoid the outcome.

I do take your meaning, reducing speed and following well established rules would have almost certainly have saved them.

0. PDF: http://www.leonardo-in-flight.nl/PDF/FieldGuide%20to%20Human...

Amazon: https://www.amazon.com/Field-Guide-Understanding-Human-Error...

I am in favor of commentary, but his comment only makes sense as hindsight. If he posted it beforehand, he would mostly be wrong, because AirBnB mostly works. If he posted it after any of the many successful outcomes, he would look dumb.

There is no reason to say that these people "got it wrong". They were unlucky. Suppose the same shitheels broke a window, climbed in, unlocked the door, and had a big party on a weekend when the owners were away. One inclined to superiority-by-hindsight could say, "Well duh, why didn't they have bars on their windows?"

After a rare negative occurrence, one can always look back with hindsight, find some way the bad outcome could theoretically have been averted, and then say, "Well duh." Always. It is a great way to sound and feel smart. But it never actually fixes anything. Indeed, it can prevent the fixing of things because, having blamed someone, we mostly stop looking for useful lessons to learn.

If you want the book-length version of this, Sidney Dekker's "Field Guide to Understanding Human Error" has a great explanation of why retrospective blame ends up being immensely harmful: http://www.amazon.com/Field-Guide-Understanding-Human-Error/...

I'm almost done with The Field Guide to Understanding Human Error: http://www.amazon.com/Field-Guide-Understanding-Human-Error/...

It's a brilliant book written by Sidney Dekker, a "Professor of Human Factors and Flight Safety". The basic point is that the default way of understanding bad outcomes is what he calls "the Old View or the Bad Apple Theory". He instead argues for the New View, where "human error is a symptom of trouble deeper inside a system".

Normally with a book like this, I read the first couple of chapters, say, "Ok, I get the idea," and can ignore the rest. After all, I both agree with and understand the basic thesis. But so far every chapter has been surprisingly useful; I keep discovering that I have Old View notions hidden away. E.g., when I discover a systemic flaw, I'm inclined to blame "bad design". But he points out that's a fancy way of calling the problem human error, just a different human and a different error than normal.

Even the driest parts are helped by his frequent use of examples, often taken from real-world aviation accident reports. There are also fascinating bits like a system for high-resolution markup of dialog transcripts to indicate timing (down to 1/10th second), speech inflection, and emphasis. I'll never use it myself, but I will definitely use the mindset that it requires.

Given how much time software projects spend dealing with bugs, I believe we need a new way to think about them, and for me this book describes a big piece of that.

Blameless postmortems work phenomenally at Etsy which is a pretty low risk setting (after reading Sidney Dekker's book The Field Guide to Understanding Human Error [highly recommended] I would say that blameless post-mortems are even more important in a high-risk setting). Except failure isn't the correct word - the book makes the case that these are natural artefacts of complex systems.

1: https://codeascraft.com/2012/05/22/blameless-postmortems/

2: http://www.amazon.com/Field-Guide-Understanding-Human-Error/...

We can't have a discussion about the human factors in automated systems without talking about Sidney Dekker's book The Field Guide To Understand Human Error:

http://www.amazon.com/Field-Guide-Understanding-Human-Error/...

Fantastic read about the futility of placing blame on a single human in a catastrophe like this. It makes a strong case for why more automation often causes more work. Definitely worth checking out, Etsy has applied it to their engineering work by using it to facilitate blameless post mortems:

http://codeascraft.com/2012/05/22/blameless-postmortems/