I used to find this perspective more persuasive and emotionally satisfying until _finally_ finding the Cognitive Systems, Resiliency, and New View of Safety people. Systems are too non-linear and interconnected for deviations from desired behavior to be solely attributable to the most proximate individual’s deficiencies. Assigning fault has organizational utility, but it does not improve outcomes.
"An absolutely critical part of every post-mortem is that it’s somebody’s fault. Every issue is either:
* Someone’s job and thus their fault when it fails
* Nobody’s job and the fault of the leader who has an ambiguous organizational design”
https://staysaasy.com/saas/2025/03/12/blameful.html?__readwiseLocation=
Mastodon Source 🐘
"Treating "error" as technical inadequacy comparable to noise fails to understand the value of "error". Paradoxically, it also blinds researchers to the workings of organizational portions of the sociotechnical system that give rise to accidents. It is not surprising that organizations continue to treat "error" as useful and objective. But this organizational behavior provides critical information about accidents that can be used to understand their genesis, evolution, and responses to them.”
Cook, Richard I., and Christopher P. Nemeth. 2010. “‘Those Found Responsible Have Been Sacked’: Some Observations on the Usefulness of Error.” Cognition, Technology & Work 12 (2): 87–93.