Build resilient systems at scale
28–30 October 2015 • Amsterdam, The Netherlands

Blame. Language. Learning: 3 tips for learning from incidents in your organisation

Lindsay Holmwood (Australian Government Digital Transformation Office)
11:50–12:30 Thursday, 29/10/2015
Location: G104/105
Average rating: ****.
(4.14, 35 ratings)
Slides:   external link

Prerequisite Knowledge

You need to have worked professionally in an organisation and been exposed to some sort of failure.


“Fail fast, fail often” is a refrain heard often throughout the tech industry. We’ve seen the successes of organisations who embrace this mantra, and have internalised that when things go wrong within our own organisations, it’s important to not just tolerate, but accept and embrace failure.

But what’s the point of embracing that failure if we’re not learning anything from it? It’s not that we’re not learning because we’re not trying – the act of embracing and learning from failure is far more complicated than most people are aware of, let alone willing to admit.

The first time you tried holding a blameless postmortem in your org, did you find the results weren’t too different from the blameful postmortems you held before? “Root cause: human error?” Have you successfully navigated these traps in your accident learning exercise, but had your findings interpreted and twisted elsewhere in your organisation?

The language we use and vantage points we hold when talking about failure shapes the outcome of that discussion. They shape how we treat people who were involved in incidents, and how capable the organisation is of learning from incidents in the future.

In this talk we’ll cover some common pitfalls when constructing a narrative for What Went Wrong. We’ll learn which cognitive biases taint our perception of events. We’ll discover how to hack our language to minimise blame.

Photo of Lindsay Holmwood

Lindsay Holmwood

Australian Government Digital Transformation Office

Lindsay Holmwood is a engineering manager living in the Australian Blue Mountains. Lindsay works at the Australian Government’s Digital Transformation Office, building clearer, simpler, faster, more humane public services . A long-time contributor to the open source and DevOps communities, he authored cucumber-nagios, Visage, and Flapjack, and has run the Sydney DevOps meetup the past five years.

Lindsay speaks internationally about both the cultural and technical side of DevOps, covering Just Culture, complexity, cognitive biases, and monitoring tools. He also won third place at the 1996 Sydney Royal Easter Show LEGO building competition.

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Picture of Lindsay Holmwood
Lindsay Holmwood
31/10/2015 7:22 CET

You can read a written version of the talk on my blog.