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> We must strive to understand that accidents don’t happen because people gamble and lose. The problem is that some accidents do happen because people gamble a
by codesections 7y ago
> We must strive to understand that accidents don’t happen because people gamble and lose.
The problem is that some accidents do happen because people gamble and lose – or rather, because people cut corners is ways that probably won't matter but sometimes really, really do.
The best approach needs to balance both causes of error. I agree that most organizations tend to err too far in the "blame someone" direction – but that doesn't mean that it's impossible to err by going too far in the other direction.
- di4na 7y agoThey cut corner because the system tell them to do so. Not because they are fundamentally flawed into liking to gamble. I can make a perfect product with zero gamble, if i get infinite money and noone need to use it.
- hoorayimhelping 7y agoAs I understand it the key to the blameless and just culture is to keep going to the bottom of it: "You cut corners. You were incentivized to cut corners. Why? Why do those incentives exist? What can we do to remove those incentives in the future?" The core of the philosophy is assuming people come to work to do a good job, and when they don't do a good job, there are reasonable explanations that involve people making locally rational decisions. The goal is to make the system stable in a way that making locally rational decisions translates to globally good decisions.
- peteradio 7y agoAnd what happens when the finger starts pointing back towards business imposing terrible incentives?
- jonfw 7y agoIf you find a business incentive as a root cause, you blamelessly discuss ways you can change that incentive.
- jiveturkey 7y agoLOL! has this ever, ever happened?
- dobbse 7y agoAs complex systems grow, The Rules™ grow into tangled conflicting messes. The mundane, every-day experts who have to live inside those complex systems must develop, among many other skills, a sense of knowing which rules to follow and which rules to violate in order to get the work done. After this incident we can say, they clearly violated this rule. They cut corners. However, we have no clear view of all the incidents they prevented in the past because they violated that rule. We cannot see that there were twenty other times when violating this rule in exactly this way was exactly what kept things working. This is the nature of hindsight bias. After the fact, it's completely obvious exactly which of the conflicting rules should have been followed. It is obvious because we now know the outcome. If you're in the thick of an incident making high-pressure, and high-consequence decisions under duress there is no way to actually predict the outcomes that will become obvious only after-the-fact. Taking a balanced approach is good universal advice for everything. But in this context, it misses the point of blameless retros. Our cultural norm is to stop investigations once we find the culprit who cut-corners. The consequences of that systemic habit are that we fail to learn and understand all of the complexity that actually contributed to the failure. We cut short our own learning. What's more, we also effectively teach everyone in the system to conceal or withhold their full understanding in the next incident. So we learn only the most shallow details about what actually happened for this incident, and we suppress what we might learn in the next incident.