打造一只心理安全感高的團(tuán)隊(duì)gettyimagesTONY

COMITI1705：36.7

荷航副機(jī)長(zhǎng)完成飛行前檢查表705：

51.2

荷航機(jī)長(zhǎng)：“是沒有，我一切已為時(shí)已晚。荷航向控制塔：“KLM4805已經(jīng)準(zhǔn)備好起飛，正在等待我們的起飛許可?！睓C(jī)場(chǎng)控斯帕爾馬斯 的 徑向交差。知道，去問一下。1706：07.4荷航機(jī)艙內(nèi)）：

好的。1706：09.6-

1706：17.8荷航向1706：19.3長(zhǎng)向控制泛美機(jī) 塔：“不……嗯?！?9.39-

1706：23.19（泛美班機(jī)和機(jī)場(chǎng)控制塔同時(shí)發(fā)話，令荷航班機(jī)無線電內(nèi)產(chǎn)生高頻噪音，三方都未意識(shí)到有重要通信漏掉）20.31705：41.5

荷航副機(jī)長(zhǎng)第一次泛美副機(jī)長(zhǎng)向控1塔：“我們還在跑道上滑行，PA1736。”（刪除線這VOR 325 ” ”

，荷話中機(jī)場(chǎng)控制塔向泛美：“明白，PA1736，請(qǐng)?jiān)陔x開主跑道后通知我?！?706：29.6-

1706：31.7泛美副機(jī)長(zhǎng)：“好的，我們會(huì)在完成后通知你。”機(jī)場(chǎng)控制塔：“謝謝。”1706：32.431705：44.6-

1705：50.81706：

荷航工程師（第二次質(zhì)疑）：“他還沒有留空跑道嗎？”1706：34.1內(nèi)）：“你說： 航4805現(xiàn)在跑道盡頭，準(zhǔn)備離開。的。”荷航工程師（第三次質(zhì)疑）：“他還沒有留空跑道嗎，那架泛美航班？”1706：35.控7

制塔：“明白，可以飛往Papa

Beacon，飛行高度9,000英尺，切入325徑向線，我們?cè)谄痫w點(diǎn)（或是“我們正在起飛”）?！焙珊綑C(jī)長(zhǎng)（艙內(nèi)）：“喔！是的?。羌芊好酪蚜艨张艿懒耍。?/p>

荷航松開剎車掣，發(fā)動(dòng)機(jī)加速。1705：53.4-

1706：08.11706：

荷航機(jī)長(zhǎng)（艙1706：29.6

什么？”提出質(zhì)疑：“等一下，我們還沒有起飛許可。”這時(shí)候荷航已經(jīng)準(zhǔn)備啟動(dòng)推進(jìn)油門。1706

34.15 “不知道通信被干擾）制泛美機(jī)長(zhǎng)（艙內(nèi)）：

我們快點(diǎn)離開這個(gè)鬼地方?！?/p>

段話與控制塔之發(fā)話沖突，KLM機(jī)組只聽到高頻噪音，控制塔亦因發(fā)荷航

？：

是泛美副機(jī)長(zhǎng)（艙內(nèi)）：

好。他很焦急，對(duì)吧？- “ “ ”25.61706：34.7長(zhǎng)（ “ ” “泛美飛行工程師（艙內(nèi)）：

是啊。讓我們等了半個(gè)多小時(shí)，那個(gè)[臟話]，現(xiàn)在他又在趕時(shí)間?！?706：40.制5

塔向荷航：“KLM4805可以飛往PapaBeacon，上升并保持飛行高度9,000英尺，起飛后右轉(zhuǎn)飛往040方向飛，直到與拉泛美機(jī)長(zhǎng)看到了約700米處荷航航班的降落燈1706：

泛美機(jī)長(zhǎng)（艙內(nèi)）：“它（KLM4805）在那……快看，見鬼它在向這邊沖過來了?！狈好里w行工程師（艙內(nèi)）：“離開！離開！快點(diǎn)離開！”200+interviews250+attributes180+teamsWhatmakesateam

effective?Psychological

SafetyPsychologicalsafetyreferstoanindividual’sperceptionoftheconsequencesoftakinganinterpersonalriskorabeliefthatateamissafeforrisktakinginthefaceofbeingseenasignorant,incompetent,negative,ordisruptive.Inateamwithhighpsychologicalsafety,teammatesfeelsafetotakerisksaroundtheirteammembers.Theyfeelconfidentthatnooneontheteamwillembarrassorpunishanyoneelseforadmittingamistake,askingaquestion,orofferinganew

idea.[Source:rework]場(chǎng)景：開會(huì)Share

informationMaking

decisionsCreating

solutionsBuilding

relationshipsAVE530%Voice

matters.RetrospectBroadcasting

informationSharinginspirationNegotiatingSource:Infographics不發(fā)問Missopportunityoflearning,get

down

to

the

bottom

of

theissues不尋求反饋Missopportunityofselfcorrection,morefrictionsincollaboration不給與反饋Lessopportunitiesofpreventingproblemstohappen不挑戰(zhàn)權(quán)威Lessteamcollaboration,moreredundantworkandultimatelylessproductivityStupidIncompetentNegativeDisruptiveCompany

MeetingWeareourownimageconsultantsandbestimageprotectors.[Source:Amy

Edmondson]Fearof

Rejection不尋求幫助No

innovation1. Employeesdon’taskmanyquestionsduring

meetings.Employeesdon’tfeelcomfortableowninguptomistakesorplaceblameonotherswhenmistakesare

made.Theteamavoidsdifficultconversationsandhot-buttontopics,hardyanydisagreementsorconflicts.Executivesandteamleaderstendtodominatemeeting

discussions.Employeesdon’toftenventureoutsideoftheirjobdescriptionsto

supportother

teammates.…Foster

PSYCHOLOGICAL

SAFETY[Source:Rework]Makeyourself

approachableBEINCLUSIVEINDECISION

MAKINGDEMONSTRATE

ENGAGEMENTSHOW

UNDERSTANDING驗(yàn)尸報(bào)告Understandroot

causePrevent

recurrenceAblamelesslywrittenpost-mortemassumesthateveryoneinvolvedinanincidenthadgoodintentionsanddidtherightthingwiththeinformationthey

had.Engineerscangiveadetailedaccountofthe

incidentwithoutfearofpunishmentorretribution.[Source:CodeCraft&GoogleSRE

handbook]場(chǎng)景一：產(chǎn)品緊急故障處理blamelessIncidentEngineer

takes

action

and

contributes

to

afailureor

incident.Management

UnawarenessManagement

becomes

less

aware

and

informed

onhow

work

is

being

performed

day

to

day,

andengineers

become

less

educated

on

lurking

or

latentconditions

for

failure

due

to

silence

mentioned

in

#4SilenceEngineersbecomesilentondetails

aboutactions/situations/observations,resultingin“Cover-Your-Ass”engineering(fromfearofpunishment)Trust

IssueReduced

trust

between

engineers

on

thegroundandmanagementlookingforsomeoneto

scapegoatPunishmentEngineerispunished,

shamed,blamed,or

retrained.More

errorsErrorsmorelikely,latent

conditionscan’t

be

identi?ed。SHAME/BLAME

CYCLE[Source:codecraft]123456IncidentEngineer

takes

action

and

contributes

to

afailureor

incident.Vulnerable

SystemAsfewer

engineers

are

solving

system

breakagetogether,

it

took

longer

time

to

pin

down

root

causeIsolated

engineerSolve

the

problem

with

much

less

helpCollaboration

IssueOther

engineers

become

less

likely

to

helptheengineeron-callduetofearofbeingtaken

accountable.PunishmentEngineerispunished,

shamed,blamed,or

retrained.Pro?t

lossErrors

persistem

longer

or

happensmore

oftenSHAME/BLAME

CYCLE[Source:codecraft]123456HumanSituationcause

errors.First

StorySecond

StoryHumanerrorisseenascauseof

failureHumanerrorisseenastheeffectofsystemic

vulnerabilitiesdeeperinsidethe

organizationSayingwhatpeopleshouldhavedoneisasatisfyingwaytodescribe

failureSayingwhatpeopleshouldhavedonedoesn’texplainwhyitmadesenseforthemtodowhatthey

didTellingpeopletobemorecarefulwillmaketheproblemgo

awayOnlybyconstantlyseekingoutitsvulnerabilitiescanorganizationsenhance

safety故障處理blamelessRegular

Post-MortemBlameless

Post-MortemYoudidn’tsendthedataontime,soIcouldn’tcreatethe

report.Ididn’tgetthedataIneededtocreatethe

report.Jamesshouldhaveorderedthepackagingsuppliessooner.Thepackagingsupplies

weren’tdeliveredon

time.Bobdidn’tproofreadthetext,soallthedocumentshadtobe

reprinted.Therewasanerrorinthetextsoallthedocumentshadtobe

reprinted.Theprojectmanagerdidn'thavecontactinformationforeveryoneontheshareddrive,soIwasn’tabletogetintouchwiththeITcontactwhentheserverwent

down.Contactinformationforeveryonewasn’tpostedontheshareddrive,soIwasn’tabletogetintouchwiththeITcontactwhentheserverwent

down.Anindividualtakinguponthemselfto

makeupforasystemic

problem..No

HeroLongticket

queuewith1-day

SLA.Hero:Theystartworking12-,

16-hourdaystomakesuretheticketSLAisupheld.Example

1HeroEveryday(includingweekends),theylookatthemonitoring,spot-check

graphs,roll

back

bad

canaries

by

hand,theyspotmemoryuseincreases

before

alerts

?re

andsubmitCLsto?xthis,theyspotoutliertasksandrestartthem

to

limit

the

damage,

etc.Example

2ProductionService

with99.99%

availability.Hero:They'llwork12-hourdaystogeteverythinginplace,andthenhand-holdtheautomation

overtheweekendto

makesurewe'rereadytorampupMondaymorning.Example

3Non

automated,?akylaunch

processBadFor

theSystemBadForthe

TeamBadfor

theIndividualLetitBreak感謝您的時(shí)間。Be

Tran?sparent透明化？PsychologicalSafety“Psychologicalsafetyreferstoanindividual’sperception

oftheconsequencesoftakinganinterpersonalriskorabeliefthatateamissafeforrisktakinginthefaceofbeingseenasignorant,incompetent,negative,ordisruptive.Inateamwithhighpsychologicalsafety,teammatesfeelsafetotakerisksaroundtheirteammembers.Theyfeelcon?dentthatnooneontheteamwillembarrassorpunish

anyone

else

for

admitting

a

mistake,

askinga

question,

or

o?ering

a

new

idea.[Source:rework]02當(dāng)我們談?wù)摴疚幕瘯r(shí)，我們?cè)谡務(wù)撌裁?？Let’swalkthroughfourcommonscenariosof

SWE!福利？口號(hào)？目標(biāo)？核心價(jià)值觀打破溝通壁壘Breakdown

communicationbarrier鼓勵(lì)信息共享Encourageinformationsharing本降低獲取信息成Makesharedinformation

easilydiscoverable降低溝通成本Reducecommunication

costBe

TransparentSUMMARY故障處理blamelessRegular

Post-MortemBlameless

Post-MortemYoudidn’tsendthedataontime,soIcouldn’tcreatethe

report.Ididn’tgetthedataIneededtocreatethe

report.Jamesshouldhaveorderedthepackagingsuppliessooner.Thepackagingsupplies

weren’tdeliveredon

time.Bobdidn’tproofreadthetext,soallthedocumentshadtobe

reprinted.Therewasanerrorinthetextsoallthedocumentshadtobe

reprinted.Theprojectmanagerdidn'thavecontactinformationforeveryoneontheshareddrive,soIwasn’tabletogetintouchwiththeITcontactwhentheserverwent

down.Contactinformationforeveryonewasn’tpostedontheshareddrive,soIwasn’tabletogetintouchwiththeITcontactwhentheserverwent

down.開會(huì)上手新項(xiàng)目產(chǎn)品應(yīng)急響應(yīng)升職9

am11am3

pm12

pmSWE的四個(gè)日常FourcommonscenariosofSWEandhowIandmyteamhasbene?tfromthetransparency

culture?場(chǎng)景一：上手新項(xiàng)目Scenarioone:new

projectCode

Search場(chǎng)景一：上手新項(xiàng)目Scenarioone:new

projectGoogleIssue

TrackerAnissueinGITisaproblemoridearelatingtoaspeci?ccomponentwithinGoogle.EveryissuehasitsownuniquepagewithinGITwhereprogress

on

addressing

the

issue

is

tracked

and

where

comments

andupdatesare

made.Cross

reference場(chǎng)景一：上手新項(xiàng)目Scenarioone:new

projectYaqsYAQS

standsfor"YetAnotherQuestionSystem".Engineersgetblockedwhile

writing

code

and

need

to

ask

questions

to

get

unblocked.

YAQS

isabetterwayforthemtogetanswerstotheirquestions.Italsocapturesthoseanswersinanewlearningformatsothenextpersonwho

has

the

same

problem

can

get

an

instant

answer.Asksimilar

questionStore

QuestionThreadRetrieve

answerNohuman

involved.Lifeofa

QuestionAwonderfulserenity

hasPAosstka

qaueqstuioen

sotniYoanqs

Sendemailtoa

specificworking

groupWorkingGroupTagWorking

GroupWhoeverisabletoanswer

thequestionrepliestothequestion

owner共享一切Share

EverythingMakeittrackableRecordtheprocessofproblemsolvinginacentralplacesothatitcanbelookeduplaterbypeoplesolvingsimilar

issues.MakeitsearchableMakeyourprocessandcodeofsolvingproblemseasilydiscoverablebyother

engineersCrossreferenceBuildyourproblemsolvingintoacompletestory.BenefitsofShare

EverythingAwonderfulserenity

hasProd

excellenceThrough

sharing

of

code

and

problem

solving

process,

it’s

hard

tohideissueslikehackycode,

unScalableSametypeofproblemsonlyneedstobesolvedonceasthesolutionisrecordedandcanbeeasilydiscoveredifengtoolsisbuiltwith

transparencyinmind.EfficiencyKnowledgesharingturnsine?cientfact-to-facecommunicationintoasearchproblemthatismoree?cientforproblemofrepetitive

nature.NecessityforcomplexsystemThemorecomplexasystem,theharderitisforoneengineertograsptheknowledgeofthewholesystemallby

himself.Knowledge

has

to

be

distrib