Learning From Lessons Learned: Preliminary Findings From a Study of Learning From Failure
CoRR(2024)
摘要
Due to various sources of uncertainty, emergent behavior, and ongoing
changes, the reliability of many socio-technical systems depends on an
iterative and collaborative process in which organizations (1) analyze and
learn from system failures, and then (2) co-evolve both the technical and human
parts of their systems based on what they learn. Many organizations have
defined processes for learning from failure, often involving postmortem
analyses conducted after any system failures that are judged to be sufficiently
severe. Despite established processes and tool support, our preliminary
research, and professional experience, suggest that it is not straightforward
to take what was learned from a failure and successfully improve the
reliability of the socio-technical system. To better understand this
collaborative process and the associated challenges, we are conducting a study
of how teams learn from failure. We are gathering incident reports from
multiple organizations and conducting interviews with engineers and managers
with relevant experience. Our analytic interest is in what is learned by teams
as they reflect on failures, the learning processes involved, and how they use
what is learned. Our data collection and analysis are not yet complete, but we
have so far analyzed 13 incident reports and seven interviews. In this short
paper we (1) present our preliminary findings, and (2) outline our broader
research plans.
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关键词
learning from failure,learning from incidents,failure driven software evolution
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