I think there are mistakes and then there are mistakes. There is a point where the postmortem needs to stop being blameless. Getting things like this wrong is

I think there are mistakes and then there are mistakes. There is a point where the postmortem needs to stop being blameless. Getting things like this wrong is an existential risk to a important institution. We can’t be genuinely concerned about lost faith in institutions and also not hold them to the highest levels of accountability.