Nice article. Something it doesn't point out, which can become one of the elements in the cycle of name/blame/shame, is the creation of 'heroes'. This is the

Nice article. Something it doesn't point out, which can become one of the elements in the cycle of name/blame/shame, is the creation of 'heroes'. This is the figure who throws themselves at the issue and brings it back from the brink of disaster. If the culture isn't fixed and failure easy to talk about, then this can play out repeatedly. Since it's usually a celebrated event ('we survived!'), it creates poor incentives for fixing the culture. One can also play this game by noticing a potential failure mode, figuring out how to fix it, but only leaping in once it's struck. I'd rather find another employer though.