Presentation: Learning From Incidents: How Things Went Right

Track: Chaos and Resilience: Architecting for Success

Location: Fleming, 3rd flr.

Duration: 2:55pm - 3:45pm

Day of week: Wednesday

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"At some level of analysis, systems are human systems since it is people who create, operate, and modify that system for human purposes, and since people, not machines, gain or suffer from the operation of that system." JC Le Coze

When things go wrong, we tend to focus on mistakes, miscalculations, and deficiencies in design. By limiting our investigations to the details of what went wrong, we ignore a far richer and more interesting source of learning: how things went right.

Research across numerous safety-critical industries such as aviation and medicine is changing what we know about how to build systems and organizations which are resilient to failure. We will look into the findings of that research and discover how we can avoid falling into common traps of investigation which curtail our ability to learn. This research shows us that the best results come when we are able to answer questions such as:

How does the system normally work?

How did we recover?

How do teams adapt to surprising circumstances?

Where did we bring expertise to the incident, and what worse outcomes did we avoid?  We will share stories from beyond the boundaries of our own industry in order to show how powerful some of these new investigative techniques can be. We will move beyond a shallow analysis of root causes and remediation items in an effort to build truly resilient engineered systems for the future. 


Speaker: Jessica DeVita

Sr. Resilience Engineering Advocate @Netflix

Jessica DeVita is a Senior Applied Resilience Engineer at Netflix where she investigates incidents and outages in production software. She is working on her MSc. in Human Factors and Systems Safety at Lund University where she is studying automation surprises in configuration management tooling. She has 20 years of experience in IT operations across industries such as medical device, entertainment, and large scale cloud computing. Previously at Chef Software, and at Microsoft, she has been invited to speak at conferences around the world on human factors, post-incident review, and devops tooling and practices.

Find Jessica DeVita at


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