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I suspect the extend and target of postmortem blame varies considerably from culture to culture. An anecdote from the railroad traffic between Germany and Denma

by igbk 4y ago

I suspect the extend and target of postmortem blame varies considerably from culture to culture. An anecdote from the railroad traffic between Germany and Denmark: "[In 2019, a DB Cargo freight train in Denmark caused an accident with a passenger train on its way to Copenhagen after a truck trailer flew off the freight train due to high winds. The German side was keen to find out who was responsible at the lowest level, i.e. the wagon inspector who had not adequately secured the freight on the freight train. The Danish side didn't care, the local authorities were concerned with structural responsibility. Not who caused the accident, but why could it happen! So in Denmark, the motto is: the process is the cause.]" - https://www.wiwo.de/unternehmen/dienstleister/zugunglueck-bei-garmisch-partenkirchen-die-deutsche-bahn-ist-zu-gestrig/28406710.html https://www.wiwo.de/unternehmen/dienstleister/zugunglueck-be... (German source)

mieko 4y ago
> keen to find out who was responsible at the lowest level It's funny how profit flows up, but legal responsibility trickles down.
- bell-cot 4y ago
  There are some old stereotypes of detail-obsessed Germans - far too busy measuring the growth rings of a tree with micrometers, and wondering why those are so close together - but never noticing that the tree is small, and growing in a well-shaded part of a large forest.
  - egberts1 4y ago
    The absolute worse case of "not seeing the forest for the tree".
SnowHill9902 4y ago
Both are important.
aeharding 4y ago
https://www.simonandschuster.com/books/There-Are-No-Accidents/Jessie-Singer/9781982129668 https://www.simonandschuster.com/books/There-Are-No-Accident...
- CSMastermind 4y ago
  Matt Parker of Youtube fame also wrote a book called Humble Pi: When Math Goes Wrong in the Real World which covers several post-mortems from the engineering space. I found it interesting that he compared and contrasted the airline industry where failures are seen as systemic (don't blame the pilot, blame the system) and the medical industry where failures are typically seen as having personal liability (blame the surgeon). https://www.penguinrandomhouse.com/books/610964/humble-pi-by-matt-parker/?pdivflag https://www.penguinrandomhouse.com/books/610964/humble-pi-by...
tokai 4y ago
Not that surprising. The wagon inspector was a dane in denmark. The organizational responsibility was on german leaders in a german company. In the end nothing happened.

by igbk 4y ago

mieko 4y ago

> keen to find out who was responsible at the lowest level It's funny how profit flows up, but legal responsibility trickles down.

bell-cot 4y ago
There are some old stereotypes of detail-obsessed Germans - far too busy measuring the growth rings of a tree with micrometers, and wondering why those are so close together - but never noticing that the tree is small, and growing in a well-shaded part of a large forest.
- egberts1 4y ago
  The absolute worse case of "not seeing the forest for the tree".

SnowHill9902 4y ago

Both are important.

aeharding 4y ago

https://www.simonandschuster.com/books/There-Are-No-Accidents/Jessie-Singer/9781982129668 https://www.simonandschuster.com/books/There-Are-No-Accident...

CSMastermind 4y ago
Matt Parker of Youtube fame also wrote a book called Humble Pi: When Math Goes Wrong in the Real World which covers several post-mortems from the engineering space. I found it interesting that he compared and contrasted the airline industry where failures are seen as systemic (don't blame the pilot, blame the system) and the medical industry where failures are typically seen as having personal liability (blame the surgeon). https://www.penguinrandomhouse.com/books/610964/humble-pi-by-matt-parker/?pdivflag https://www.penguinrandomhouse.com/books/610964/humble-pi-by...

tokai 4y ago

Not that surprising. The wagon inspector was a dane in denmark. The organizational responsibility was on german leaders in a german company. In the end nothing happened.