Complex System Failures and Blameless Retrospectives
summary
Case study of a 1990 Seattle floating bridge failure where investigators find five contributing factors (uneven pumping, added wastewater in pontoons, rain and wave surge, preexisting cracks, storm timing) and estimate $69 million damage; explains the engineering modeling used, the operational gap of an inconsistent pumping schedule, and why filling pontoons with waste water almost worked until it didn’t. Covers concrete practices for blameless retrospectives, asking how not why, and an incident retrospective template.
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chapters (8)
- 0:00Complex system failures
- 1:08I-90 floating bridge disaster
- 7:42Blaming individuals fails
- 10:53Human error not root cause
- 13:43Right-hand rule for failures
- 16:00Effective blameless retrospectives
- 18:22Retrospective participants
- 20:07Retrospectives to actionable change
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