The issue with attributing failure, no matter how little suffering there is, is that it provides a huge incentive to not self report and/or downplay incidents.

The issue with attributing failure, no matter how little suffering there is, is that it provides a huge incentive to not self report and/or downplay incidents. Unless you are acting with malice, your actions are a product of the system and procedures in place. Those should be the focus of improvement, not individuals. E.g. preventing prod pushes that contain unreviewed code. Of course we need to talk about individuals, but that's performance management and not incident management.