A couple weeks ago, my wife & I went to Basilica Block Party, a local music festival. It was a good time, and OH MANS you have to see Fitz & The Tantrums live. Their sax player is a hero unit.

Anyhoo, we walked over to the porta-potties between sets. The lines were about 8–10 people long. And my spouse suggested an intriguing strategy for minimizing her wait time. I will call this strategy The Strategy:

The Strategy: All else being equal, get in the line with the most men.

The reasoning behind The Strategy is obvious: women take longer to pee than men, so if 2 queues are the same length, then the faster-moving queue should be the one with fewer women. It’s intuitive, but due to my current obsession with queueing theory, I became intensely interested in the strategy’s implications. In particular, I started to wonder things like:

  • How much can you expect to shave off your wait time by following The Strategy?
  • How does the effectiveness of The Strategy vary with its popularity? Little’s Law tells us that the overall average wait time won’t be affected, but is The Strategy still effective if 10% of the crowd is using it? 25%? 90%?

And then I thought to myself “I could answer these questions through the magic of computation!”


Lately I’ve been seeing queueing systems everywhere I go, so I figured it’d be worthwhile to write a generic queueing system simulator to satisfy my curiosity. That’s what I did. It’s called qsim.

To quote the README,

A queueing system in qsim processes arbitrary jobs and is composed of 5 pieces:

  • The arrival process controls how often jobs enter the system.
  • The arrival behavior defines what happens when a new job arrives. When the arrival process generates a new job, the arrival behavior either sends it straight to a processor or appends it to a queue.
  • Queues are simply holding pens for jobs. A system may have many queues associated with different processors.
  • A queueing discipline defines the relationship between queues and processors. It’s responsible for choosing the next job to process and assigning that job to a processor.
  • Processors are the entities that remove jobs from the system. A processor may take differing amounts of time to process different jobs. Once a job has been processed, it leaves the queueing system.

qsim provides a framework for implementing these building blocks and putting them together, and it also provides hooks that can be used to gather data about a simulation as it runs. I’m really looking forward to using qsim to gain insight into all sorts of different systems.

For now: porta-potties.

The porta-potty simulation

You’ll recall The Strategy:

The Strategy: All else being equal, get in the line with the most men.

To determine the effectiveness of The Strategy, I implemented PortaPottySystem using qsim. Here are some of the assumptions I made:

  • People arrive very frequently, but if all the queues are too long (8 people) they leave.
  • There are 15 porta-potties, each with its own queue. Once a person enters a queue, they stay in that queue until the corresponding porta-potty is vacant.
  • Shockingly, I couldn’t find any reliable data on the empirical distribution of pee times by sex, so I chose a normal distribution with a mean of 40 seconds for men and 60 seconds for women.
  • Most people just pick a random queue to join (as long as it’s no longer than the shortest queue), but some people use The Strategy of getting into the queue with the highest man:woman ratio (again, as long as it’s no longer than the shortest queue).
  • Nobody’s going number 2 because that’s gross.
  • Everyone is either a man or a woman. I know all about gender being a spectrum, and if you want to submit a pull request that smashes the gender binary, please do.

The first question I wanted to answer was: how does using The Strategy affect your wait time?

To answer this question, I ran a simulation where the probability of a given person deciding to use The Strategy is 1%. The other 99% of people simply join one of the shortest queues without regard to its man:woman ratio. I ran 20 simulations, each for the equivalent of 2 weeks, and came up with these wait time distributions:


More of a box-plot person? I hear ya:


The Strategy is definitely not a huge win here. On average, your wait time will be reduced by about 10–15 seconds (4–6%) if you use The Strategy. Still, it’s not nothing, right?

Now how does the benefit of using The Strategy vary with its popularity? This is actually really interesting. I never would have guessed it. But the data shows that you should always use The Strategy, even if everybody else is using it too.

Here I’ve charted average wait times against the proportion of people using the strategy. Colors are more prominent where the data set in question is large (and therefore heavily influences the overall average):


You’ll notice that the overall average (dark green) does not vary with Strategy popularity. This is good news, because otherwise we’d be violating Little’s Law, which would probably just mean our simulation was broken.

The interesting thing here is that the benefit of using The Strategy decreases pretty much linearly as its popularity increases, but at the same time there accrues a disadvantage to not using it. If everybody else in the system is using The Strategy, and you come along and decide not to, you can still expect to wait 10 seconds longer than everybody else. Therefore using The Strategy is unequivocally better than not using The Strategy.

Unless of course you don’t really care about those 10 seconds, in which case you should do whatever you want.

When we imagine how to use a resource effectively – be that resource a development team, a CPU core, or a port-a-potty – our thoughts usually turn to efficiency. Ideally, the resource gets used at 100% of its capacity: we have enough capacity to serve our needs without generating queues, but not so much that we’re wasting money on idle resources. In practice there are spikes and lulls in traffic, so we should provision enough capacity to handle those spikes when they arrive, but we should always try to minimize the amount of capacity that’s sitting idle.

Except what I just said is bullshit.

In the early chapters of Donald G. Reinertsen’s brain-curdlingly rich Principles of Product Development Flow, I learned a very important and counterintuitive lesson about queueing theory that puts the lie to this naïve aspiration to efficiency-above-all-else. I want to share it with you, because once you understand it you will see the consequences everywhere.

Queueing theory?

Queueing theory is an unreasonably effective discipline that deals with systems in which tasks take time to get processed, and if there are no processors available then a task has to wait its turn in a queue. Sound familiar? That’s because queueing theory can be used to study basically anything.

In its easiest-to-consume form, queueing theory tells us about average quantities in the steady state of a queueing system. Suppose you’re managing a small supermarket with 3 checkout lines. Customers take different, unpredictable amounts of time to finish their shopping. So they arrive at the checkout line at different intervals. We call the interval between two customers reaching the checkout line the arrival interval.

And customers also take different, unpredictable amounts of time to get checked out. The time it takes from when the cashier scans a customer’s first item to when they finish checking that customer out is called the processing time.

Each of these quantities has some variability in it and can’t be predicted in advance for a particular customer. But you can empirically determine the probability distribution of these quantities:


Given just the information we’ve stated so far, queueing theory can answer a lot of questions about your supermarket. Questions like:

  • How long on average will a customer have to wait to check out?
  • What proportion of customers will arrive at the checkout counter without having to wait in line?
  • Can you get away with pulling an employee off one of the registers to go stock shelves? And if you do that, how will you know when you need to re-staff that register?

These sorts of questions are super important in all sorts of systems, and queueing theory provides a shockingly generalizable framework for answering them. Here’s an important theme that shows up in a huge variety of queueing systems:

The closer you get to full capacity utilization, the longer your queues get. If you’re using 100% of capacity all time, your queues grow to infinity.

This is counterintuitive but absolutely true, so let’s think through it.

What happens when you have no idle capacity

What the hell? Isn’t using capacity efficiently how you’re supposed to get rid of queues? Well yes, but it doesn’t work if you do it all the time. You need some buffer capacity.

Let’s think about a generic queueing system with 5 processors. This system’s manager is all about efficiency, so the system operates at 100% capacity all the time. No idle time. That’s ideal, right?


Sure, okay, now what happens when a task gets completed? If we want to make sure we’re always operating at 100% capacity, then there needs to be a task waiting behind that one. Otherwise we’d end up with an idle processor. So our queueing system must look more like this:


In order to operate at 100% capacity all the time, we need to have at least as many tasks queued as there are processors. But wait! That means that when another new task arrives, it has to get in line behind those other tasks in the queue! Here’s what our system might look like a little while later:


Some queues may be longer than others, but no queue is ever empty. This forces the total number of items in the queue to grow without limit. Eventually our system will look like this:


If you don’t quite believe it, I don’t blame you. Go back through the logic and convince yourself. It took me a while to absorb the idea too.

What this means for teams

You can think of a team as a queueing system. Tasks arrive in your queue at random intervals, and they take unpredictable amounts of time to complete. Each member of the team is a processor, and when everybody’s working as hard as they can, the system is at 100% capacity.

That’s what a Taylorist manager would want: everybody working as hard as they can, all the time, with no waste of capacity. But as we’ve seen, in any system with variability, that’s an unachievable goal. The closer you get to full capacity utilization, the faster your queues grow. The longer your queues are, the longer the average task waits in the queue before getting done. It gets bad real fast:


So there are very serious costs to pushing your capacity too hard for too long:

  • Your queues get longer, which itself is demotivating. People are less effective when they don’t feel that their work is making a difference (see The Progress Principle)
  • The average wait time between a task arriving and a getting done rises linearly with queue length. With long wait times, you hemorrhage value: you commit time and energy to ideas that might not be relevant anymore by the time you get around to them (again: read the crap out of Principles of Product Development Flow)
  • Since you’re already operating at or near full capacity, you can’t even deploy extra capacity to knock those queues down: it becomes basically impossible to ever get rid of them.
  • The increased wait time in your ticket queue creates long feedback times, nullifying the benefit of agile techniques.

Efficiency isn’t the holy grail

Any queueing system operating at full capacity is gonna build up giant queues. That includes your team. What should you do about it?

Just by being aware that this relationship exists, you can gain a lot of intuition about team dynamics. What I’m taking away from it is this: There’s a tradeoff between how fast your team gets planned work done and how long it takes your team to get around to tasks. This changes the way I think about side projects, and makes me want to find the sweet spot. Let me know what you take away from it.

Maybe you’ve been here:

You get a phone call in the middle of the night. The new sysadmin (whom you hired straight out of college) is flipping all of her shits because web app performance has degraded beyond the alert threshold. She’s been clicking through page after page of graphs, checking application logs all the way up and down the stack, and just generally cussing up a storm because she can’t find the source of the issue. You open your laptop, navigate straight to overall performance graphs, drill down to database graphs, see a pattern that looks like mutex contention, log in to the database, find the offending queries, and report them to the on-call dev. You do all this in a matter of minutes.

Or here:

You’re trying to teach your dad to play Mario Kart. It’s like “Okay, go forward… no, forward… you have to press the gas – no, that’s fire – press the gas button… it’s the A button… the blue one… Yeah, there you go, okay, you’re going forward now… so… so go around the corner… why’d you stop? Dad… it’s like driving a car, you can’t turn if you’re stopped… so remember, gas is A… which is the blue one…”

Why is it so hard for experts to understand the novice experience? Well, in his book Sources of Power, decision-making researcher Gary Klein presents some really interesting theories about what makes experts experts. His theories give us insight into the communication barriers between novices and experts, which can make us better teachers and better learners.

Mental Simulation

Klein arrived at his decision-making model, the recognition-primed decision model, by interviewing hundreds of experts over several years. According to his research, experts in a huge variety of fields rely on mental simulation. In Sources of Power, he defines mental simulation as:

the ability to imagine people and objects consciously and to transform those people and objects through several transitions, finally picturing them in a different way than at the start.

Klein has never studied sysadmins, but when I read about his model I recognized it immediately. This is what we do when we’re trying to reason out how a problem got started, and it’s also how we figure out how to fix it. In our head, we have a model of the system in which the problem lives. Our model consists of some set of moving parts that go through transitions from one state to another.

If you and your friend are trying to figure out how to get a couch around a corner in your stairwell, your moving parts are the couch, your body, and your friend’s body. If you’re trying to figure out how a database table got corrupted, your moving parts might be the web app, the database’s storage engine, and the file system buffer. You envision a series of transitions from one state to the next. If those transitions don’t get you from the initial state to the final state then you tweak your simulation and try again until you get a solution.

Here’s the thing, though: we’re people. Our brains have a severely limited amount of working memory. In his interviews with experts about their decision making processes, Klein found that there was a pretty hard upper limit on the complexity of our mental simulations:

  • 3 moving parts
  • 6 transitions

That’s about all we get, regardless of our experience or intelligence. So how do experts mentally simulate so much more effectively than novices?


As we gain experience in a domain, we start to see how the pieces fit together. As we notice more and more causal patterns, we build a mental bank of abstractions. An abstraction is a kind of abbreviation that stands in for a set of transitions or moving parts that usually functions as a whole. It’s like the keyboard of a piano: when the piano’s working correctly, we don’t have to think about the Rube Golberg-esque series of yanks and shoves going on inside it; we press a key, and the corresponding note comes out.

Experts have access to a huge mental bank of abstractions. Novices don’t yet. This makes experts more efficient at creating mental simulations.

When you’re first learning to drive a car, you have to do everything step by step. You don’t have the abstraction bank of an experienced driver. When the driving instructor tells you to back out of a parking space, your procedure looks something like this:

  • Make sure foot is on brake pedal
  • Shift into reverse
  • Release brake enough to get rolling
  • Turn steering wheel (which direction is it when I’m in reverse?)
  • Put foot back on brake pedal
  • Shift into drive

It’s a choppy, nerve-racking sequence of individual steps. But once you practice this a dozen times or so, you start to build some useful abstractions. Your procedure for backing out of a parking space becomes more like:

  • Go backward (you no longer think about how you need to break, shift, and release the brake)
  • Get facing the right direction
  • Go forward

Once you’ve done it a hundred times, it’s just one step: “Back out of the parking space.”

Now if you recall that problem solving involves mental simulations with at most 3 moving parts and 6 transitions, you’ll see why abstractions are so critical to the making of an expert. Whereas a novice requires several transitions to represent a process, an expert might only need one. The right choice of abstraction allows the expert to hold a much richer simulation in mind, which improves their effectiveness in predicting outcomes and diagnosing problems.


Klein highlights another important difference between experts and novices: experts can readily process counterfactuals: explanations and predictions that are inconsistent with the data. This is how experts are able to improvise in unexpected situations.

Imagine that you’re troubleshooting a spate of improper 403 responses from a web app that you admin. You expect that the permissions on some cache directory got borked in the last deploy, so you log in to one of the web servers and tail the access log to see which requests in particular are generating 403s. But you can’t find a single log entry with a 403 error code! You refresh the app a few times in your browser, and sure enough you get a 403 response. But the log file still shows 200 after 200. What’s going on?

If you were a novice, you might just say “That’s impossible” and throw up your hands. But an experienced sysadmin could imagine any number of plausible scenarios to accommodate this counterfactual:

  • You logged in to staging instead of production
  • The 403s are only coming from one of the web servers, and it’s not the one you logged in to
  • 403s are being generated by the load balancer before the requests ever make it to the web servers
  • What you’re looking at in your browser is actually a 200 response with a body that says “403 Forbidden”

Why are experts able to adjust so fluidly to counterfactuals while novices aren’t?

It comes back to abstractions. When experts see something that doesn’t match expectations, they can easily recognize which abstraction is leaking. They understand what’s going on inside the piano, so when they expect a tink but hear a plunk, they can seamlessly jump to a lower level of abstraction and generate a new mental simulation that explains the discrepancy.

Empathizing with novices

By understanding a little about the relationship between abstractions and expertise, we can teach ourselves to see problems from a novice’s perspective. Rather than getting frustrated and taking over, we can try some different strategies:

  1. Tell stories. When Gary Klein and his research team want to understand an expert’s thought process, they don’t use questionnaires or ask the expert to make a flow chart or anything artificial like that. The most effective way to get inside an expert’s thought process is to listen to their stories. So when you’re teaching a novice how to reason about a system, try thinking of an interesting and surprising troubleshooting experience you’ve had with that system before, and tell that story.
  2. Use the Socratic method. Novices need practice at juggling abstractions and digesting counterfactuals. When a novice is describing their mental model of a problem or a potential path forward, ask a hypothetical question or two and watch the gears turn. Questions like “You saw Q happen because of P, but what are some ways we could’ve gotten to Q without P?” or “You expect that changing A will have an effect on B, but what would it mean if you changed A and there was no effect on B?” will challenge the novice to bounce between different layers of abstraction like an expert does.
  3. Remember: your boss may be a novice. Take a moment to look around your org chart and find the nearest novice; it may be above you. Even if your boss used to do your job, they’re a manager now. They may be rusty at dealing with the abstractions you use every day. When your boss is asking for a situation report or an explanation for some decision you made, keep in mind the power of narratives and counterfactuals.

I’ve been reading a really excellent book on product development called The Principles of Product Development Flow, by Donald G. Reinertsen. It’s a very appealing book to me, because it sort of lays down the theoretical and mathematical case for agile product development. And you know that theory is the tea, earl grey, hot to my Jean-Luc Picard.

But as much as I love this book, I just have to bring up this chart that’s in it:

terrible chart

This is the Hindenburg of charts. I can’t even, and it’s not for lack of trying to even. Being horrified by the awfulness of this chart is left as an exercise for the reader, but don’t hold me responsible if this chart gives you ebola.

But despite the utter contempt I feel for that chart, I think the point it’s trying to make is very interesting. So let’s talk about highways.


Highways need to be able to get many many people into the city in the morning and out of the city in the evening. So when civil engineers design highways, one of their main concerns is throughput, measured in cars per hour.

Average throughput can be measured in a very straightforward way. First, you figure out the average speed, in miles per hour, of the cars on the highway. The cars are all traveling different speeds depending on what lane they’re in, how old they are, etc. But you don’t care about all that variation: you just need the average.

The other thing you need to calculate is the density of cars on the highway, measured in cars per mile. You take a given length of highway, and you count how many cars are on it, then you repeat. Ta-da! Average car density.

Then you do some math:

\frac{cars}{hour} = \frac{cars}{mile} \cdot \frac{miles}{hour}

Easy peasy. But let’s think about what that means. Here’s a super interesting graph of average car speed versus average car speed:

speed vs speed

Stay with me. Here’s a graph of average car density versus average car speed:

density vs speed

This makes sense, right? Cars tend to pack together at low speed. That’s called a bumper-to-bumper traffic jam. And when they’re going fast, cars tend to spread out because they need more time to hit the brakes if there’s a problem.

So, going back to our equation, what shape do we get when we multiply a linear equation by another linear equation? That’s right: we get a parabola:


That right there is the throughput curve for the highway (which in the real world isn’t quite so symmetric, but has roughly the same properties). On the left hand side, throughput is low because traffic is stopped in a bumper-to-bumper jam. On the right hand side, throughput is low too: the cars that are on the highway are able to go very fast, but there aren’t enough of them to raise the throughput appreciably.

So already we can pick up a very important lesson: Faster movement does not equate to higher throughput. Up to a point, faster average car speed improves throughput. Then you get up toward the peak of the parabola and it starts having less and less effect. And then you get past the peak, and throughput actually goes down as you increase speed. Very interesting.


Now, looking at that throughput curve, you might be tempted to run your highway at the very top, where the highest throughput is. If you can get cars traveling the right average speed, you can maximize throughput thereby minimizing rush hour duration. Sounds great, right?

Well, not so fast. Suppose you’re operating right at the peak, throughput coming out the wazoo. What happens if a couple more cars get on the highway? The traffic’s denser now, so cars have to slow down to accommodate that density. The average speed is therefore reduced, which means we’re now a bit left of our throughput peak. So throughput has been reduced, but cars are still arriving at the same rate, so that’s gonna increase density some more.


This is congestion collapse: a sharp, catastrophic drop in throughput that leads to a traffic jam. It can happen in any queueing system where there’s feedback between throughput and processing speed. It’s why traffic jams tend to start and end all at once rather than gradually appearing and disappearing.

The optimal place for a highway to be is just a little to the right of the throughput peak. This doesn’t hurt throughput much because the curve is pretty flat near the top, but it keeps us away from the dangerous positive feedback loop.

So what does all this have to do with product development workflow?

Kanban Boards Are Just Like Highways

On a kanban board, tickets move from left to right as we make progress on them. If we had a kanban board where tickets moved continuously rather than in discrete steps, we could measure the average speed of tickets on our board in inches per day (or, if we were using the metric system, centimeters per kilosecond):

ticket-speedAnd we could also measure the density of tickets just like we measured the density of cars, by dividing the board into inch-wide slices and counting the tickets per inch:

tickets-per-inchLet’s see how seriously we can abuse the analogy between this continuous kanban board and a highway:

  • Tickets arrive in our queue at random intervals, just as cars pull onto a highway at random intervals.
  • Tickets “travel” at random speeds (in inches/day) because we’re never quite sure how long a given task is going to take. This is just like how cars travel at random speeds (in miles per hour)
  • Tickets travel more slowly when there are many tickets to do (because of context switching, interdependencies, blocked resources, etc.), just as cars travel more slowly when they’re packed more densely onto the highway.
  • Tickets travel more quickly when there are fewer tickets to do, just as cars travel more quickly when the road ahead of them is open.

There are similarities enough that we can readily mine traffic engineering patterns for help dealing with ticket queues. We end up with a very familiar throughput curve for our kanban board:

ticket-throughputAnd just like with highway traffic, we run the risk of congestion collapse if we stray too close to the left-hand side of this curve. Since kanban boards generally have a limit on the number of tickets in progress, however, our congestion won’t manifest as a board densely packed with tickets. Rather, it will take the form of very long queues of work waiting to start. This is just as bad: longer queues mean longer wait times for incoming work, and long queues don’t go away without a direct effort to smash them.

What we can learn from real-world queues

A kanban board is a queueing system like any other, and the laws of queueing theory are incredibly general in their applicability. So we can learn a lot about managing ticket throughput by looking at the ways in which other queueing systems have been optimized.

Measure your system’s attributes

First off: you need metrics. Use automation to measure and graph, at the very least,

  • Number of tickets in queue (waiting to start work)
  • Number of tickets in progress
  • Number of tickets completed per day (or week)

Productivity metrics smell bad to a lot of people, and I think that’s because they’re so often used by incompetent managers as “proof” that employees could be pulling more weight. But these metrics can be invaluable if you understand the theory that they fit into. You can’t improve without measuring.

Control occupancy to sustain throughput

As we’ve seen, when there are too many tickets in the system, completion times suffer in a self-reinforcing way. If we’re to avoid that, we need to control the number of tickets not just in progress, but occupying the system as a whole. This includes queued tickets.

In some cities (Minneapolis and Los Angeles, for example), highway occupancy is controlled during rush hour by traffic lights on the on-ramp. The light flashes green to let a single car at a time onto the highway, and the frequency at which that happens can be tuned to the current density of traffic. It’s a safeguard against an abrupt increase in density shoving throughput over the peak into congestion collapse.

But how can we control the total occupancy of our ticketing system when tickets arrive at random?

Don’t let long queues linger

If you’re monitoring your queue length, you’ll be able to see when there’s a sharp spike in incoming tickets. When that happens, you need to address it immediately.

For every item in a queue, the average wait time for all work in the system goes up. Very long queues cause very long wait times. And long queues don’t go away by themselves: if tickets are arriving at random intervals, then a long queue is just as likely to grow as it is to shrink.

One way to address a long queue is to provision a bit more capacity as soon as you see the queue forming. Think about supermarkets. When checkout lines are getting a bit too long, the manager will staff one or two extra lanes. All it takes is enough capacity to get the queues back down to normal – it’s not necessary to eliminate them altogether – and then those employees can leave the register and go back to whatever they were doing before.

The other way to address a long queue is to slash requirements. When you see a long queue of tickets forming, spend some time going through it and asking questions like

  • Can this ticket be assigned to a different team?
  • Can this feature go into a later release?
  • Are there any duplicates?
  • Can we get increased efficiency by merging any of these tickets into one? (e.g. through automation or reduced context switching)

If you can shave down your queue by eliminating some unnecessary work, your system’s wait times will improve and the required capacity to mop up the queue will be lower.

Provide forecasts of expected wait time

At Disney World, they tell you how long the wait will be for each ride. Do you think they do this because it’s a fun little bit of data? Of course not. It helps them break the feedback loop of congestion.

When the wait for Space Mountain is 15 minutes, you don’t think twice. But when the wait is an hour, you might say to yourself “Eh, maybe I’ll go get lunch now and see if the line’s shorter later.” So these wait time forecasts are a very elegant way to cut down on incoming traffic when occupancy is high. Just like those traffic lights on highway on-ramps.

Why not use Little’s law to make your own forecasts of expected ticket wait time? If you’re tracking the occupancy of your system (including queued tickets) and the average processing rate (in tickets completed per day), it’s just:

\text{Average Wait Time} = \frac{\text{Occupancy}}{\text{Average Processing Rate}}

If you display this forecast in a public place, like the home page for your JIRA project, people will think twice when they’re about to submit a ticket. They might say to themselves “If it’s gonna take that many days, I might as well do this task myself” or “The information I’m asking for won’t be useful a week from now, so I guess there’s no point filing this ticket.”

Forecasts like this allow you to shed incoming ticket load when queues are high without having to tell stakeholders “no.”

Queues are everywhere

If you learn a little bit about queueing theory, you’ll see queues everywhere you look. It’s a great lens for solving problems and understanding the world. Try it out.





It’s a great idea to track your MTTR (Mean Time To Recover) as an operational metric. MTTR is defined as the average interval between onset of a failure and recovery from that failure. We acknowledge that failures are part of the game, so we want our organization to be good at responding quickly to them. It’s intuitive that we’d want our MTTR to trend down.

This is one of those places where our intuition can be misleading.

MTTR is an average over incidents of incident duration. That means that the total amount of downtime gets denominatored out. Consider these two brothers who run different websites:

  • Achenar’s site only had 1 outage in September, and it lasted 60 minutes.
  • Sirius’s site had 120 outages in September, lasting 20 minutes each.

Sirius had 40 times as much downtime as Achenar in the month of September. Sirius’s MTTR, however, was 1/3 that of Achenar: 20 minutes rather than 60 minutes.

Lowering your MTTR is a good strategy in certain situations. But you need to make sure it’s the right strategy. If you don’t look at the whole picture, things like nuisance alarms and insufficient automation can be confounded with the meaning of your MTTR. If you fix a whole bunch of meaningless alerts that always recover quickly without intervention (you know the type), your MTTR goes up!



MTTR is useful to track, and it can be useful for decision-making. Just remember: our goal is to minimize downtime and noise, not MTTR. If the path of least resistance to lower downtime and a stronger signal is to respond to incidents quicker, then MTTR is your best friend. But that’s not always true.

I often meet with skepticism when I say that server monitoring systems should only page when a service stops doing its work. It’s one of the suggestions I made in my Smoke Alarms & Car Alarms talk at Monitorama this year. I don’t page on high CPU usage, or rapidly-growing RAM usage, or anything like that. Skeptics usually ask some variation on:

If you only alert on things that are already broken, won’t you miss opportunities to fix things before they break?

The answer is a clear and unapologetic yes! Sometimes that will happen.

It’s easy to be certain that a service is down: just check whether its work is still getting done. It’s even pretty easy to detect a performance degradation, as long as you have clearly defined what constitutes acceptable performance. But it’s orders of magnitude more difficult to reliably predict that a service will go down soon without human intervention.

We like to operate our systems at the very edge of their capacity. This is true not only in tech, but in all sectors: from medicine to energy to transportation. And it makes sense: we bought a certain amount of capacity: why would we waste any? But a side effect of this insatiable lust for capacity is that it makes the line between working and not working extremely subtle. As Mark Burgess points out in his thought-provoking In Search of Certainty, this is a consequence of nonlinear dynamics (or “chaos theory“), and our systems are vulnerable to it as long as we operate them so close to an unstable region.

But we really really want to predict failures! It’s tempting to try and develop increasingly complex models of our nonlinear systems, aiming for perfect failure prediction. Unfortunately, since these systems are almost always operating under an unpredictable workload, we end up having to couple these models tightly to our implementation: number of threads, number of servers, network link speed, JVM heap size, and so on.

This is just like overfitting a regression in statistics: it may work incredibly well for the conditions that you sampled to build your model, but it will fail as soon as new conditions are introduced. In short, predictive models for nonlinear systems are fragile. So fragile that they’re not worth the effort to build.

Instead of trying to buck the unbuckable (which is a bucking waste of time), we should seek to capture every failure and let our system learn from it. We should make systems that are aware of their own performance and the status of their own monitors. That way we can build feedback loops and self-healing into them: a strategy that won’t crumble when the implementation or the workload takes a sharp left.


People make mistakes, and that’s fine.

We’ve come a long way in recognizing that humans are integral to our systems, and that human error is an unavoidable reality in these systems. There’s a lot of talk these days about the necessity of blameless postmortems (for example, this talk from Devops Days Brisbane and this blog post by Etsy’s Daniel Schauenberg), and I think that’s great.

The discussion around blamelessness usually focuses on the need to recognize human interaction as a part of a complex system, rather than external force. Like any system component, an operator is constrained to manipulate and examine the system in certain predefined ways. The gaps between the system’s access points inevitably leave blind spots. When you think about failures this way, it’s easier to move past human errors to a more productive analysis of those blind spots.

That’s all well and good, but I want to give a mathematical justification for blamelessness in postmortems. It follows directly from one of the fundamental theorems of probability.

Bayes’ Theorem

Some time in the mid 1700s, the British statistician and minister Thomas Bayes came up with a very useful tool. So useful, in fact, that Sir Harold Jeffreys said Bayes Theorem “is to the theory of probability what Pythagoras’s theorem is to geometry.”

Bayes’ Theorem lets us perform calculations on what are called conditional probabilities. A conditional probability is the probability of some event (we’ll call it E) given that another event (which we’ll call D) has occurred. Such a conditional probability would be written


The “pipe” character between ‘E’ and ‘D’ is pronounced “given that.”

For example, let’s suppose that there’s a 10% probability of a traffic jam on your drive to work. We would write that as

P(\{\mbox{traffic jam}\}) = 0.1

That’s just a regular old probability. But suppose we also know that, when there’s an accident on the highway, the probability of a traffic jam quadruples up to 40%. We would write that number, the probability of a traffic jam given that there’s been an accident, using the conditional probability notation:

P(\{\mbox{traffic jam}\}|\{\mbox{accident}\}) = 0.4

Bayes’ Theorem lets us use conditional probabilities like these to calculate other conditional probabilities. It goes like this:

P(A|B) = \frac{P(B|A)P(A)}{P(B)}

In our traffic example, we can use Bayes’ Theorem to calculate the probability that there’s been an accident given that there’s a traffic jam. Informally, you could call this the percentage of traffic jams for which car accidents are responsible. Assuming we know that the probability of a car accident on any given morning is 1 in 5, or 0.2, we can just plug the events in which we’re interested into Bayes’ Theorem:

P(\{\mbox{accident}\}|\{\mbox{traffic jam}\}) = \frac{P(\{\mbox{traffic jam}\}|\{\mbox{accident}\})P(\{\mbox{accident}\})}{P(\{\mbox{traffic jam}\})}

P(\{\mbox{accident}\}|\{\mbox{traffic jam}\}) = \frac{0.4 \cdot 0.2}{0.1}

P(\{\mbox{accident}\}|\{\mbox{traffic jam}\}) = 0.8 = 80\%


Bayes’ Theorem can give us insight into the usefulness of assigning blame for engineering decisions that go awry. If you take away all the empathy- and complexity-based arguments for blameless postmortems, you still have a pretty solid reason to look past human error to find the root cause of a problem.

Engineers spend their days making a series of decisions, most of which are right but some of which are wrong. We can gauge the effectiveness of an engineer by the number N of decisions she makes in a given day and the probability P(M) that any given one of those decisions is a mistake.

Suppose we have a two-person engineering team — Eleanor and Liz — who work according to these parameters:

  • Eleanor: Makes 120 decisions per day. Each decision has a 1-in-20 chance of being a mistake.
  • Liz: Makes 30 decisions per day. Each decision has a 1-in-6 chance of being a mistake.

Eleanor is a better engineer both in terms of the quality and the quantity of her work. If one of these engineers needs to shape up, it’s clearly Liz. Without Eleanor, 4/5 of the product wouldn’t exist.

But if the manager of this team is in the habit of punishing engineers when their mistakes cause a visible problem (for example, by doing blameful postmortems), we’ll get a very different idea of the team’s distribution of skill. We can use Bayes’ Theorem to see this.

The system that Eleanor and Liz have built is running constantly, and let’s assume that it’s exercising all pieces of its functionality equally. That is, at any time, the system is equally likely to be executing any given behavior that’s been designed into it. (Sure, most systems strongly favor certain execution paths over others, but bear with me.)

Well, 120 out of 150 of the system’s design decisions were made by Eleanor, so there’s an 80% chance that the system is exercising Eleanor’s functionality. The other 20% of the time, it’s exercising Liz’s. So if a bug crops up, what’s the probability that Eleanor designed the buggy component? Let’s define event A as “Eleanor made the decision” and event B as “The decision is wrong”. Bayes’ theorem tells us that

P(A|B) = \frac{P(B|A)P(A)}{P(B)}

which, in the context of our example, lets us calculate the probability P(A|B) that Eleanor made a particular decision given that the decision was wrong (i.e. contains a bug). We already know two of the quantities in this formula:

  • P(B|A) reads as “the probability that a particular decision is wrong given that Eleanor made that decision.” Referring to Eleanor’s engineering skills above, we know that this probability is 1 in 20.
  • P(A) is the probability that Eleanor made a particular decision in the system design. Since Eleanor makes 120 decisions a day and Liz only makes 30, P(A) is 120/150, or 4 in 5.

The last unknown variable in the formula is P(B): the probability that a given design decision is wrong. But we can calculate this too; I’ll let you figure out how. The answer is 11 in 150.

Now that we have all the numbers, let’s plug them in to our formula:

P(A|B) = \frac{[1/20] \cdot [4/5]}{[11/150]}

P(A|B) = 0.545 = 54.5\%

In other words, Eleanor’s decisions are responsible for 54.5% of the mistakes in the system design. Remember, this is despite the fact that Eleanor is clearly the better engineer! She’s both faster and more thorough than Liz.

So think about how backwards it would be to go chastising Eleanor for every bug of hers that got found. Blameful postmortems don’t even make sense from a purely probabilistic angle.

But but but…

Could Eleanor be a better engineer by making fewer mistakes? Of course. The point here is that she’s already objectively better at engineering than Liz, yet she ends up being responsible for more bugs than Liz.

Isn’t this a grotesquely oversimplified model of how engineering works? Of course. But there’s nothing to stop us from generalizing it to account for things like the interactions between design decisions, variations in the severity of mistakes, and so on. The basic idea would hold up.

Couldn’t Eleanor make even fewer mistakes if she slowed down? Probably. That’s a tradeoff that Eleanor and her manager could discuss. But the potential benefit isn’t so cut-and-dry. If Eleanor slowed down to 60 decisions per day with a mistake rate of 1:40, then

  • fewer features (40% fewer!) would be making it out the door, and
  • a higher proportion of the design decisions would now be made by bug-prone Liz, such that the proportion of decisions that are bad would only be reduced very slightly — from 7.33% to 7.22%

So if, for some crazy reason, you’re still stopping your postmortems at “Eleanor made a mistake,” stop it. You could be punishing engineers for being more effective.


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