An interview with Dave Zwieback on how to effectively get to the root cause of incidents by removing blame from the analysis.
Contains some great quotes:
“Say there’s an incident and five minutes into the postmortem, we find out what happened and who’s responsible: Bobby and Susan screwed up. That feels good because there’s an unambiguous explanation: the so-called ‘root cause’. In this case, we’ve found our ‘bad apples,’ and can deal with them punitively so that such failures will never happen again. We may even feel better about our company culture and our colleagues if the individuals accept the blame and own up to what they did to ‘cause’ the incident,” says Zwieback.
The truth is that the most critical learning has been left on the table because we’ve overlooked the deeper context of the incident. “If we remove Bobby and Susan from the equation, could we be sure that the incident would never happen again? No. In all likelihood, the conditions that contributed to the negative outcome — that fragility that was necessary for the incident to occur — are still there. What’s worse, the two folks who know the most about these conditions — Bobby and Susan — are no longer there to help learn from this incident, and make the system more resilient. And others who have information that could materially improve future outcomes now have even more reasons to withhold it because they don’t want to be punished. That’s the problem with blame and punishment.” says Zwieback.
Dave also recommends ditching Post Mortems for “Learning Reviews” (although I’m not sure if I’ll change the title of this blog just yet..)
The purpose of the learning review is to learn so that we can improve our systems and organizations. No one will be blamed, shamed, demoted, fired, or punished in any way for providing a full account of what happened. Going beyond blame and punishment is the only way to gather full accounts of what happened—to fully hold people accountable.
A great article, definitely worth the time to read.