This article on Etsy’s approach to learning from mistakes is pretty interesting: Blameless PostMortems and a Just Culture.
Most of us have read the script about the importance of embracing mistakes but it’s easier in theory than in practice. This article has some thoughtful analysis of why this is, and what can be done about it.
This is how it summarises the blame model:
If we go with “blame” as the predominant approach, then we’re implicitly accepting that deterrence is how organizations become safer. This is founded in the belief that individuals, not situations, cause errors. It’s also aligned with the idea there has to be some fear that not doing one’s job correctly could lead to punishment. Because the fear of punishment will motivate people to act correctly in the future.
In practice, this approach leads to more errors because people cover up, and thus remove the possibility of learning. The alternative is to take a more reflective approach that sees systems, not immoral individuals, as the issue.
A funny thing happens when engineers make mistakes and feel safe when giving details about it: they are not only willing to be held accountable, they are also enthusiastic in helping the rest of the company avoid the same error in the future. They are, after all, the most expert in their own error. They ought to be heavily involved in coming up with remediation items.
I’m just summarising, the whole thing is worth reading.
Hat tip: Simon Bostock