Omnipresent availability risks in cloud software

I’m using this post to gather together some common threads I’ve noticed after reading write-ups of major cloud software incidents. By cloud software, I’m referring to software-as-a-service (do people even say that anymore? in the cloud. This doesn’t just apply to cloud providers, although it does apply to them as well.

Here’s an outline of the topics in this post:

  • problem areas
    • saturation
      • example: databases
    • networking (traffic routing failure)
      • example: DNS
    • security (deny valid access)
      • example: SSL certificates
  • essential non-standard changes
    • mitigating an operational issue
    • migration
  • essential increase in essential complexity
    • reliability subsystem
    • migration

I think of all of these as omnipresent availability risks: I think these are fundamentally unavoidable, and will be contributing to software incidents until the end of time; or, at the very least, until the end of my own career in software.

There are three general areas that most major incidents seem to fall into: saturation, networking, and security. So, let’s start with those.

Saturation

Saturation is probably the topic I talk about most frequently, both on this blog and elsewhere (e.g.,: the saturation post I wrote for the Resilience in Software Foundation and my saturation talk at the Software Should Work conference). The system becomes saturated when it reaches a limit. That’s a pretty generic description, but there are many limits!

Databases

Many major incidents involve some system component becoming saturated in one form or another. I personally worry about database saturation the most. That’s because it’s difficult to recover from an overloaded production database. In addition, because database systems are such complex beasts, it can be quite difficult to even determine what the specific performance issue actually is. This is why having in-house database operational expertise is critical.

Saturation is an omnipresent risk because the finite nature of resources is a hard constraint in the world that we live in. Eventually, some resource in your system is going to run out.

Example: GitHub Incident, Aug 26, 2026

Networking

While I prattle on endlessly about saturation, not every major incident involves saturation. You can encounter scenarios where all of your internal subsystems are reporting healthy, but from your customer’s point of view, your site is down: they can’t use it. One way this can happen is if your users can’t even reach your site, and that’s where the networking problem area comes in.

A networking problem can lead to packets being misrouted. These requests might be black-holed (i.e., silently dropped), or they might be incorrectly routed to a service that doesn’t have the capacity to respond to all of these requests, in which case you’ve got both a network routing issue and a saturation issue.

A visual depiction of an actual black hole. Image source: NASA

DNS

DNS issues are an example of this kind of network-related failure mode. There’s no way those packets are going to make it to their destination if the client can’t even determine which IP address to send them to. And when DNS breaks, that’s what happens.

I bring DNS up because it’s bitten folks enough times that there’s a famous haiku:

More generally, networking is an omnipresent risk because cloud software is inherently distributed, so networking is always a critical service. Now, I don’t work in networking, but from the outside, networking just feels like a dangerous domain to do operational stuff in. The blast radius of a networking issue can be very large. And, because network behavior is inherently distributed, reasoning about the behavior of operational changes is just inherently difficult. Honestly, that’s probably why I don’t work in networking.

And, so, I predict we’ll continue to see networking issues contribute to large-scale incidents.

Example: Buildkite incident, Aug 25, 2026

Security

There’s a fundamental tradeoff between availability and security: availability is about ensuring that the good people can access the system. Security is about ensuring that the bad people cannot access the system. This means that there’s always a risk that a security system designed to prevent bad actors from accessing the system can lead to good actors also being blocked. Consider this scenario: there’s an internal security subsystem that goes unhealthy (possibly due to saturation). Is your policy to fail closed or fail open in the event that this subsystem is erroring? Answering that requires making an availability-security tradeoff.

SSL certificate expiration

Another example of this failure mode, which keeps biting our industry again and again, is SSL certificate expiration. Here you have the behavior of a security system that is preventing legitimate access because the cert wasn’t renewed.

Bazel expired certificate
Even the mighty Google encounters SSL certificate expirations. This is from the Bazel incident

And so, my claim is availability incidents that involve security subsystems will continue to be a thing forever.

Example: Bazel incident, Sep 27, 2025

Essential uncommon changes

Your system is constantly undergoing change. Heck, if you stopped making changes, the system would eventually stop working properly. Now, there are some changes that your org does very frequently. Hopefully, you’re deploying often, flipping feature flags a lot, and so on. But there are other changes that your org has less experience with, because they happen much less often. That means that there hasn’t been as much investment in tooling to support these sorts of changes, and it means that the people making these changes don’t have the same level of expertise as they do with the more common changes. That makes these sorts of changes more dangerous: less mature tooling and less experienced humans.

Mitigating an operational issue

A few years ago, I wrote a post titled a conjecture on why reliable systems fail where I speculated on two common contributors to major incidents. One of those contributors was a manual intervention that was intended to mitigate a minor incident. Now, it may be that you frequently have to do manual interventions to mitigate system issues, in which case you’ll have a lot of experience with those sorts of interventions. But you’ll also be more motivated to put in the engineering effort to automate away those sorts of common issues.

It’s exactly the uncommon issues that require a human operator to intervene to mitigate that are dangerous, because they are uncommon. But they’re essential: there’s a problem in the system, and you need to fix it! But because all practitioner actions are gambles, the manual mitigation carries risk that you could make the problem even worse. And, eventually, this will happen to you.

Example: Azure Regional Outage, Jul 23, 2026

Migration

If you’re at a tech company, unless it’s a start-up, you’ll be dealing with migrations, as old tech gets replaced by newer tech that is better suited to the problems that your org is currently facing. While migrations as a general category are extremely common, each migration is itself a snowflake. This means that the specific details of the migration work is an uncommon change. The work of migration involves making a kind of change to your system that you haven’t made before.

To make things worse, one of the dangers of migration is that, as you go along, you start to build confidence that your changes are safe, but there are actually hidden dangers lurking in the system for the next migration. The confidence in the safety of the work exceeds the actual safety. I mean, you made n-1 changes as part of the migration, and none of those changes had negative consequences. It’s natural to assume that the same outcome will occur with the nth change.

Example: Rogers Network outage, Jul 8, 2022

Essential increase in essential complexity

The late American computer scientist Fred Brooks wrote a famous software engineering essay titled No Silver Bullet where he drew a distinction between accidental complexity and essential complexity. The general idea was that there was some amount of complexity in a software system that didn’t need to be there (accidental complexity) and some amount that was just inherent to the nature of the problem space and solution space and so could not be removed (essential complexity).

Reliability subsystem

We’ve developed multiple techniques to improve the reliability of software systems, including retries, concurrency limiting, autoscaling, automated failover, circuit breakers, health checks, canaries, outlier detection, the list goes on and on. There’s one thing that all of these techniques have in common: they increase the complexity of the overall system! And they do this because they have to increase complexity in order to do their job. This is a consequence of Ashby’s Law, which states that if you want to build a control system that handles more scenarios, you have to increase the complexity of the controller itself.

This means that reliability subsystems result in a complexity trade-off. On the one hand, our system can now automatically recover from failure modes that previously required manual intervention. On the other hand, as we all know, increase in complexity is itself dangerous because it can introduce entirely new failure modes that weren’t there before.

Going back to my conjecture blog post, the second contributor I posited was: unexpected behavior of a subsystem whose primary purpose was to improve reliability. And this is exactly why. Adding reliability subsystems improves the robustness of our system, but it adds essential complexity to our system, which can lead to novel incidents.

Example: OpenAI incident, Dec 11, 2024

Migration

Like all engineers, I’m a big fan of giving the answer “it depends” if somebody asks me a question about whether they should do X or Y. However, if someone came up to me and said, “Lorin, I’m preparing to do a migration at my company, and I’m trying to decide whether to do a big-bang migration or an incremental one”, then I would almost certainly say, “For the love of God, please do an incremental migration!”. Sometimes big-bang migrations are unavoidable, but when given a choice, I’m going to go for the incremental migration as the safer option.

However, when you do an incremental migration, it means that you need to simultaneously support the old system and the new system at the same time while you’re doing the migration. This means that even if the new system yields a net decrease in overall complexity over the old system, while the migration is happening, you’re going to see an increase in system complexity. And that means that you’ll see incidents arise as a byproduct of this increased complexity.

Example: Cloudflare incident, Jul 14, 2025

Incidents are inevitable, so you’d better be ready

To reiterate, I think all of the risks mentioned here are omnipresent: they are fundamental to the nature of cloud software. I don’t think that any of these risks can be eliminated. That’s why I believe so strongly in the value of getting better at incident response. Because, if you prepare, you can get better at dealing with problems that arise as a result of these risks.

GitHub, autoscaling, and the component substitution fallacy

In yesterday’s post about the recent GitHub outage, there was a detail in the writeup that I didn’t say anything about: the autoscaling policy on the service with the saturated Istio sidecar.

Originally this was caused by an Istio sidecar pod reaching its concurrency limits and failing to auto scale correctly because of a misconfigured policy that watched host service but not sidecar limits.

I suspect readers of this blog are familiar with what autoscaling is and how it works, but here’s a brief summary in case you aren’t. The amount of compute and memory resources that a service requires depends on the load that’s placed on that service. The relevant source of load here is external requests against the service, also known as traffic. The volume of traffic varies over time. For example, for a company like GitHub, my guess is that they more traffic during working hours than evening and weekends.

Given that load changes dynamically, and that the compute and memory resources a service need is a function of load, there are two general strategies. One strategy is to provision your service for peak load. The other strategy is to dynamically adjust the resources allocated to your service, based on its current load; that’s called autoscaling.

If you want your service to use autoscaling, you need to define an autoscaling policy. In particular, you need to pick which metrics you want to use that represent load, and then you need to specify how resources should be added or removed based on how that metric changes.

CPU utilization is a common metric used for autoscaling. But note that a service can become saturated even if CPU is low. For example, imagine a scenario where you use thread-per-request with a threadpool, and the latency of your downstream requests increase, and all of the threads in the pool end up blocked. Here the service is saturated, and you’d benefit from spinning up new pods, but CPU is actually low, because the threads are blocked waiting on I/O (this happened to Slack back in 2021). Now, you can add additional rules to your autoscaling policy to handle such cases (which is what Slack did, where they rapidly scaled up based on number of threads). Or you can scale based on incoming request volume instead of CPU, if your service isn’t CPU-bound.

Based on the GitHub writeup, it sounds like the autoscaling policy for the impacted service used load metrics that only took into account load on the service itself, and not on the Istio sidecar.

In general, each service behaves differently under load, which means that every autoscaling policy is effectively bespoke. This means that a team that owns a service is not only responsible for the business logic, but also for an operational control system with custom parameters, that can really only be checked via load testing. (Are you doing load testing on all your services?) The service owners are also almost certainly not autoscaling experts. And so it’s not surprising to me that a misconfigured autoscaling policy was a contributor here.

But, while I think it’s worth discussing the particular defect with this policy, since it’s good for people to be aware of the risks of autoscaling, I also think it’s too easy to fixate on it to the exclusion of other factors involved in this incident. This is what David Woods refers to as the component substitution fallacy – the idea that the way to improve reliability is to focus efforts on identifying and fixing the defective components.

While, yes, you should identify and fix the defects uncovered by an incident, you should also recognize that:

This means that component defects aren’t enough to take down your system, or your system would be down right now. Don’t just look at the individual components: treat the interactions as first-class. In the GitHub outage, we see discussion of interactions between factors such as: changing traffic patterns (including scrapers), autoscaling policy, the Istio sidecar saturation, retry logic, HAProxy node saturation, and authentication traffic.

There’s also a multitude of details we don’t have because this is a rapidly disseminated public writeup, and the good stuff can only be found in the internal writeup. I speculated in this post about the relationship between service owner and autoscaling policy, but I would love to know more about the history here (did this policy predate the use of Istio sidecars, for example?). I’d also love to know more about the problematic traffic. (What kinds of requests were they? Was it a sudden increase or a gradual ramp-up? Do we know why the traffic increased?).

You can’t get answers to these sorts of questions for public incident writeups, but you can for the internal ones at your own organization. It’s up to you to ask the questions.

GitHub has another tough day

On August 6, 2026, GitHub had a pretty rough incident: GitHub Actions was degraded for about nine hours. GitHub posted a public incident write-up. It’s only a few paragraphs long, but there are some interesting details in here.

This was yet another incident that involved saturation. In fact, the write-up even uses the word saturated when describing what happened.

The incident was triggered by a routine deployment to an internal Actions service responsible for processing events and generating Actions jobs. The deployment exposed an existing capacity and concurrency weakness. As pods were replaced during the deployment, remaining capacity became saturated, causing services to crash and triggering a cascading impact across multiple clusters and downstream services.

We often think of deployments as risky because we are changing the code that’s running in production, and the execution of that new code could trigger a behavior change in the system that could lead to an incident. But a deployment is itself also an operational change in the behavior of the system: our system behaves differently during a deployment than it does when nothing is being deployed. Ironically, this is one of the advantages of deploying more frequently: the more often we are deploying, the more that deployment becomes a normal part of the system behavior – we get more experience with the system in deploying state.

In this particular case, running in the deploying state reduces the number of pods available for doing work, as the older pods go online. In this scenario, it sounds like the system was running close enough to the margin that the reduction in capacity due to the deploy pushed the system over the edge, leading to a cascading failure. This is what the resilience folks call a brittle collapse, which is when the system fails in a non-graceful way when it reaches saturation.

As is common when recovering an overloaded the system, they got it back to healthy by shedding load (throttling) and by increasing capacity.

These services recovered at 17:00 after expanding capacity, throttling incoming webhook-triggered work to allow the system to recover, and increasing processing capacity for the backlog of affected events.

I wish the write-up had more details on what was involved in enabling throttling and getting that additional capacity to come online. In particular, I’m curious about whether this was easy to do or difficult. But, alas, you typically don’t get those kinds of details on public writeups.

And, of course, because every incident involves multiple contributing factors, there was a previously undiscovered bug that made things worse by consuming available capacity trying to run invalid jobs:

Due to a latent bug in one of the services responsible for job assignment, runners were getting assigned jobs that were no longer valid and then getting stuck retrying those jobs, preventing them from picking up valid work.

I would love to know more details about how the heck they figured out what was going on with these stuck jobs. I can just imagine being a responder to this incident, trying to get the backlog of work processed, and discovering that there are workers are blocked trying to execute invalid jobs! How did they figure out they were stuck? How did they figure out this was because of a bug?

They deployed a change to work around this problem, but I would love to know what kind of change that was. Was it a quick workaround to get things moving again? I bet it was, but we’ll never know…

This second stage of impact was mitigated by deploying changes to prevent runners from repeatedly attempting to acquire invalid jobs. These mitigations allowed the accumulated queues to drain and Actions to recover to normal operation.

The write-up ends with the typical “here’s what we’re doing to make sure this doesn’t happen again” text, but I am heartened by the last sentence (emphasis mine):

We are also making additional improvements to reduce the risk of cascading failures and accelerate recovery during large-scale Actions disruptions.

Too often, the focus of reliability work is entirely on prevention. I’m happy to see them also focus on preparing to recover more quickly. Because, as we all know, the next big incident is always just around the corner.

Traditional versus resilience engineering views

As a fan of resilience engineering, I often differ with people on where we should focus our scarce engineering cycles in order to improve reliability.

I thought it would be a useful exercise to brainstorm some of the differences in focus between what I’ll call the traditional view of reliability, and the resilience engineering view.

Traditional view focuses on Resilience engineering view focuses on
accountabilitycoordination
prioritizationgoal conflicts
risk mitigationrisk trade-offs
better processes and conformance thereofmore expertise
quantitativequalitative
root causeinteraction of multiple factors
action itemsinsight
preventing future incidents,
ensuring all incidents are novel
better handling of novel incidents
reducing complexitynavigating complexity
objectivesproduction pressure
robustnessresilience
human variability as liabilityhuman variability as asset
building accurate system modelrepairing inevitable model errors
rigorimprovisation
explicit knowledgetacit knowledge
automation, benefits ofautomation, risks introduced by

Dear researchers column

The Journal of System and Software publishes a regular column called Dear Researchers: The perspective of software practitioners. Each column is an open letter to the software engineering research community from someone who works in tech. It’s edited by Austin Henley and Olaf Zimmermann, both of whom have experience in the two worlds of academia and industry.

They invited me to submit a column, which I did. When it finally gets published, you’ll be able to find it here: Dear researchers: help me deal with incidents! The published version will eventually go behind the journal’s paywall, but here’s a preprint of the column that you can always read free of charge.

The demon of the gaps

Mephistopheles (a medieval demon from German folklore) flying over Wittenberg, in a lithograph by Eugène Delacroix.

Modern software systems contain within them a mind-boggling level of complexity. As software engineers, we make this complexity manageable through techniques like decomposition, information hiding, and abstraction. We endeavor to break our systems up into components that interact over well-defined interfaces. By doing this, the surface exposed to individual software engineers is dramatically reduced: no individual has to understand how the entire complex system works in order to contribute to their system. Instead, each software engineer needs to understand only the individual component that they work on, along with the interfaces of the other components that they interact with. Decomposition is synonymous with analysis, where you study a larger thing by breaking it up into smaller pieces that are more amenable to understanding.

You can see this strategy of complexity management in action in microservice architectures. An engineer needs to understand the service that their team owns, and the interfaces of the services that their team calls out to. This architecture effectively bounds the information that an engineer needs in order to work effectively. Microservice architectures aren’t there for scaling the software itself, they’re there for scaling the software organization.

Unfortunately, when the system breaks down, this complexity management strategy breaks down itself. Just as hurricanes don’t respect political boundaries, system failures don’t respect component boundaries. Yes, sometimes the problem in a software system is limited to the failure of a single component. Those are the easiest cases to diagnose and mitigate. However, the hairy incidents are the ones that arise due to unexpected interactions across components. Maybe you have several services that are throwing errors, or maybe none of the services are throwing errors but customers are still seeing incorrect behavior. There’s no obvious change that correlates with the start of impact, or maybe you don’t even know when the impact started because the customer impact isn’t reflected in your existing metrics.

When you’re in the throes of an incident that involves an unexpected interaction, this architecture that was built for managing complexity now works against you. Because you’ve built an analysis solution but you’re now faced with a synthesis problem. You need to understand how the pieces all normally fit together to function in order to determine what is going wrong with the system right now. You’ve optimized to avoid requiring anybody to understand how the whole thing works, but now the whole thing isn’t working, and no one person knows how the whole thing works.

The job of the incident responders is to collectively figure out how to do that synthesis. You’ve brought together a group of people who each understand the functions of different components of the system, and you need to work together to build enough of an understanding of how the system functions to debug what’s going wrong. As an ad hoc team, the incident responders have to move up and down the abstraction hierarchy to figure this out.

This sort of in-the-moment reconstruction of system function from component parts is an essential part of incident response for the most complex incidents, but it’s rarely treated as first-class work that’s worthy of study and support. The recent book Crisis Engineering by Marina Nitze, Matthew Weaver, and Mikey Dickerson is the exception that proves the rule: they do discuss the work of building a model of the system during a crisis to help figure out what’s gone wrong. But I struggle to recall any other guidance I’ve read about incident response that talks about how to prepare for doing this sort of work. It’s important work, and it’s difficult, and the ability to do it well can have a huge impact on the time it takes to mitigate the hardest incidents. This is stuff that even the best individual humans struggle with, because it involves a group of humans working together effectively, with each person having a partial model of the system. And if the best humans struggle with it, I don’t think AI SRE tools are going to save us here: if the best humans struggle, the AIs will too. We need to figure out how to get better at this collectively. Like so many things, it’s a coordination problem.

Reliability as a game of improving the odds

I’m a betting man; I just enjoy making bets, even when there are no stakes at all.

Examples of my enjoyment of betting

And when you talk about bets, you end up talking about odds.

It turns out that reliability is also about odds, even though we don’t use the language of odds in our domain. Consider how we talk about availability. We report system availability as a number of nines: for example, we might say “four nines of availability”, which means 99.99% of somethings are good over some time interval. The canonical example of those somethings are successful requests. In that case, if someone says a service has four nines of availability over the past three months, that means that 99.99% of requests succeeded over that time period. We could express the same information by saying that there is a one in ten-thousand chance that any given request failed in the past three months.

If your system has exhibited four nines of availability in the past three months, and you assume that the availability of your system in the near future will be like the availability of the past (a dangerous and unwarranted assumption, but let’s go with it for a moment), then we could also express this information using the language of odds, by stating that the odds of a request failing are ten-thousand to one.

But this isn’t a post about describing availability in the language of odds. Instead, what I want to talk about is how all reliability work is inherently about improving the odds, increasing the likelihood that the system stays up. Any time we build any sort of reliability mechanism, be it load shedding, autoscaling, canarying, staged deployments, automated rollbacks, or what have you, we are building automation into the system that either eliminates or reduces the impact a subset of potential problems. If you ask an engineer working on improving reliability, “will this prevent all future incidents”, they will tell you “no, of course not”.

However, we don’t explicitly think of reliability work in terms of improving the odds. Instead, we tend to think of it as deterministically addressing a specific class of problem. You’ll hear questions like, “how many historical incidents would this tech have prevented?” in trying to determine whether engineering should invest in a particular reliability solution. They are looking for an answer like, “this would have prevented 20% of our SEV1s and SEV0s”. This 20% isn’t interpreted as a likelihood, instead it’s used as an estimate of impact, as in “this will improve our availability by around 20%”. The idea is that this reliability work will deterministically eliminate or mitigate a certain fraction of incidents; we just don’t know exactly what that fraction is, so we estimate it from historical data.

What I would like to propose in this post is that we think about all of the various kinds of reliability work as improving the odds of our system being up longer, instead of assuming that reliability work will have a fixed effect, and try to estimate the effect size. I’ve got two motivations for taking this perspective of reliability work as odds improvement.

The first motivation is that I don’t think we can ever estimate the effect size without error bars that are so huge that the estimates are themselves meaningless. As I’ve written about previously, the variation in incidents is just too large relative to the amount of data we have available. And, to make the estimation problem from historical data even worse, our system is changing over time. Or, to put it in technical terms, I don’t believe that incidents can be modeled as a stationary process. (Heck, if they were stationary, then that means that reliability work could not have an impact, because then the process would change over time!). Note that I’ve never seen anybody try to validate the estimates, they’re always point-in-time estimates used to justify work, and then promptly forgotten about. In one sense, that’s fine, they served their purpose of convincing leadership that we should allocate cycles for a particular kind of reliability work. But we shouldn’t fool ourselves into believing that these estimates are meaningful: they’re for persuasion, not insight.

It’s my second motivation, though, that prompted me to write this blog post. And that’s because the idea of reliability work as improving the odds of effectively mitigating future incidents is a useful framework for thinking about work that improves resilience. I’m interested in improving the skills of the people who respond to incidents, putting them in a better position to deal with those future unforeseen, surprising scenarios. One way to do this is learning from how responders dealt with previous incidents, the different sorts of observability data they had access to and how, the different knobs that were able to turn, and so on. While the next incidents will be different, the set of tools that are available during incident response are generally the same. There’s no way I can give a quantitative of estimate how this sort of skill improvement work will impact reliability. And despite the enormous number of random factors, I am confident that it will improve our odds.

Flipping the bozo bit on flips the learning off

I’m too young to have seen Bozo the Clown myself, but I’m old enough to get the references

“Flipping the bozo bit” is an expression from the software world. Think about a time when you reached a point where you simply stopped respecting the opinion of a particular person, most likely a co-worker. From that point on, you disregarded what they said. This is what flipping the bozo bit is. This person isn’t worth listening to, they’re a bozo.

There’s a related phenomenon, where we hear an anecdote about some bad outcome that happened to someone else, and our conclusion is that this outcome occurred because, well, that person is a bozo. I’m writing, of course, about incidents. You’ve seen this happen, right? An incident happens, the details of the incident get passed around, and somebody makes a comment like, “how could they have [not] done X?” The subtext is “what a bunch of bozos!”

This is on my mind because of the latest AI-related incident that befell PocketOS. You can read about it in the Twitter post written by the PocketOS founder, Jer Crane. The post is titled An AI Agent Just Destroyed Our Production Data. It Confessed in Writing. Unsurprisingly, this post got a lot of online attention. I saw a lot of “wow, was this guy ever a bozo” reactions to this story. I want to talk about why this reaction is counter-productive. I also want to call out the technical term for this phenomenon, which is a cousin of flipping the bozo bit. It’s called distancing through differencing.

The term distancing through differencing was introduced by the American resilience engineering researchers Richard Cook and David Woods in their 2006 paper: Distancing Through Differencing: An Obstacle to Organizational Learning Following Accidents. Technically, it’s a book chapter, from Resilience Engineering: Concepts and Precepts. It’s very readable, and I recommend it. All of the quoted text below is from that paper.

By focusing on the differences, they see no lessons for their own operation and practices.

When people hear about an incident and respond by concluding “an incident like that would never happen to us; that happened to those workers over there because they are clearly not as careful as we are, that’s distancing through differencing in action.

Overall they decided the incident “couldn’t happen here”.

The Cook and Woods paper illustrates the phenomenon with a case study of a chemical fire that broke out at an American manufacturing plant. There had been a similar fire that had occurred previously at the same company, at an overseas plant. The American employees knew about the previous fire, but they had concluded that there was nothing to learn from that other fire, as that sort of accident couldn’t happen to them in the U.S. After all, those overseas workers were less skilled, less motivated, and less careful. In short, those overseas workers were perceived as different.

Ironically, after the chemical fire at the Ameircan plant, other workers at that very same plant also exhibited distancing through differencing.

Workers in the same plant, working in the same area in which the fire occurred but on a different shift, attributed the fire to lower skills of the workers on the other shift.

Cook and Woods note that our tendency to focus on differences between us and them when the incident happens to them leads us to miss aspects of the system that we actually have in common with them. By focusing on the differences, we miss the opportunity to learn from their experiences, because it seduces us into believing there’s nothing for us to learn here.

do not discard other events because they appear on the surface to be dissimilar. At some level of analysis, all events are unique; while at other levels of analysis, they reveal common patterns.

Now let’s circle back to the PocketOS AI-related incident. If we come to the conclusion that PocketOS employees were simply using AI irresponsibly, and that we are more responsible than that, we learn nothing from the experience. I was heartened to see that Railway, the vendor used by PocketOS that exposed the delete API, has made changes to the overall system to improve safety; see their post: Your AI wants to nuke your database. Guardrails fix that.

Stepping back, this isn’t the last AI-related incident we’re going to see in our industry, not by a long shot. The next time you read one of those, if your reaction is “they should have known not to do X”, then you’ve fallen into the distancing through differencing trap.

(As an aside, “they should have known…” is an incoherent sentence. It’s one thing if somebody deliberately took on excessive risk. But it’s another thing if they unknowingly took on excessive risk. How can you blame a person for not knowing something?)

When this process of learning moved past the obstacle of distancing through differencing in this case, the organizational response changed.

After all, there but for the grace of God go we all.

How incidents can teach us about what’s already working well

Here’s a famous optical illusion, which was developed by the American neuroscientist Edward H. Adelson.

Source

Even though square A appears darker than square B, the two are, in fact, the exact same shade of gray. It’s such a powerful illusion that, even knowing the illusion doesn’t destroy its effect; you’ll still “see” the illusion after you know about it. It’s so powerful that you may not believe me over your lying eyes. If you’re on macOS, you can confirm the illusion by opening the Digital Color Meter app and hovering your mouse pointer over each square in turn. You’ll see that both squares have the same RGB value. In hex, the value is #646464.

I’m going to suggest two stylized reactions to witnessing this illusion. One reaction is to say, “Oh, no! This illusion clearly illustrates a flaw in the human visual system! We should work on developing a vision correction technology so that people don’t fall victim to problems that would arise from this failure mode in human visual processing.”

A very different reaction is to say, “Oh, wow! This illusion gives us a hint into how the human visual system functions! Our brain must contain a prior model about the relationship between light, shadow, and objects, and is imposing that model when processing the signals coming from our optic nerve. This illusion appears to be an example of a pathological case which violates the human brain’s model.”

The first reaction is, admittedly, a ridiculous strawman. These sorts of illusions are harmless, so there’s no motivation to try to “correct” from them. After all, it’s no coincidence that the illusion was developed by a researcher who studies human vision. Even though our visual system is failing us in this strange case, the value of an illusion like this is not to learn the circumstances in which our vision fails, but instead to use the failure to gain insight into how our vision works so effectively for the vast majority of the time.

Last week, I wrote a post about Safety-II, the idea that we will learn more about how to create reliability in our system by studying the (common) successful cases rather than the (rare) failure cases. But we can also use the failure cases to learn about how the system normally succeeds! Just as neuroscientists can use optical illusions (where the vision system fails) to learn how the visual system succeeds, we can use incidents (when our system fails) to learn about how our system succeeds.

To make this more concrete, imagine you’re in an incident review meeting, and one of the incident responders, someone who is a real expert at your company, is talking about how, in hindsight, they misdiagnosed the problem during the incident. The signals that they saw misled them until thinking that the system was in state A, when really the system was in state B. And that led to the incident taking much longer to resolve, because the responders went down the wrong path.

The typical sort of question to ask in a review meeting would be along the lines of “what can we do to make sure we don’t misdiagnose this type of problem in the future?” But, there’s a very different question that you ask. And that question is, “how did the responder come to the conclusion the system was in state A?” Asking this question will expose details about the responder’s mental model of how the system actually works. If the responder was an expert, and they were led astray by the signals, then it’s likely that this incident was a pathological case, an operational equivalent of the optical illusion we saw above. By asking the responder about how they made the diagnosis, you are giving the meeting attendees the opportunity to learn from the expert responder. Similarly, you can ask the responder, “how did you finally figure out that the system was in state B?”, which will give you another chance to retroactively witness the work of an expert in action.

Like optical illusions, incidents are pathological cases. But, unlike illusion, incidents aren’t harmless. This means that the natural reaction is, “what went wrong here, and how do we stop doing that?” But if our goal is improvement, we should recognize there’s a lot more leverage in maximizing the opportunity to learn about what’s working well today, from the experts who are doing that work well. After all, there’s a reason we called that responder an expert; their work had led to a lot more success than failure.

Life comes at you fast

 Now, here, you see, it takes all the running you can do, to keep in the same place. – Lewis Carroll, Through the Looking-Glass, and What Alice Found There

LLM coding may be revolutionizing software development productivity, but it doesn’t seem to be generating the same sorts of gains in software reliability yet. Two events that caught my eye today, although only one is directly related to LLMs.

The first event was that Anthropic suffered from another incident today, which lasted about an hour and a half.

This brought Claude Code down to one nine over the past 60 days, although they’re at two nines if you look over 90 days. I know, I know, I shouldn’t even talk about the nines, but they do make for a great screenshot.


The second event, the one I really want to focus in here, was GitHub’s CTO Vlad Fedorov writing the blog post: An update on GitHub availability. It was only six weeks ago that he wrote Addressing GitHub’s recent availability issues, which is clearly a sign that GitHub is concerned about the impact of recent incidents on their brand.

I want talk about GitHub’s post in the context of David Woods’s Messy 9 collection of patterns about complex systems. I’ve mentioned them before, but to re-iterate, they are: congestion, cascades, conflicts, saturation, lag, friction, tempos, surprises, tangles.

Fedorov notes that AI is driving a lot more activity on the site: the counts of pull requests, commits, repos are growing like never before.

Source: An update on GitHub availability

This is a great example of an increase in tempo: the environment that GitHub exists within is changing faster than it has previously. Heck, it’s right there in the title of that graphic: “Record Acceleration”. In particular, the load on GitHub as a system has increased significantly, and GitHub is struggling to keep up with this load. It puts GitHub at risk of saturation.

This exponential growth does not stress one system at a time. A pull request can touch Git storage, mergeability checks, branch protection, GitHub Actions, search, notifications, permissions, webhooks, APIs, background jobs, caches, and databases. At high scale, small inefficiencies compound: queues deepen, cache misses become database load, indexes fall behind, retries amplify traffic, and one slow dependency can affect several product experiences.

GitHub has to make changes to its internal systems in order to handle this load. I don’t work at GitHub, so I don’t know the details, but I have high confidence that they can’t simply horizontally scale their way out of the problem. They will likely have to rearchitect parts of their system in order to handle the increased load. And that will take time, even in the age of AI. And this is where the lags come in. It takes time to actually implement long-term solutions that can handle the load, which increases the probability of short-term outages since the system is running too close to the margin, and those outages delay the long-term solution work because the short-term firefighting steals engineering cycles, and so on. It’s a dangerous place to be, and I don’t envy them.

(As an aside, one other aspect of Fedorov’s post that I found interesting was how the increasing popularity of monorepos is also putting additional stress on GitHub as a system. People are using them in ways that designers had not envisioned!)

I don’t know whether Anthropic will reveal any details about the nature of their most recent outage, but as I’ve written about previously, the author of Claude Code mentioned on Twitter that Anthropic’s availability issues are related to unexpectedly rapid increases in demand. They are victims of their own success.

One of the reasons I don’t expect AI to improve reliability is that I don’t think LLMs are well-suited to mitigate the risk of saturation. As GitHub demonstrates, LLMs are more likely to be on the supply side when it comes to risk of saturation.