Comment by Aurornis
10 hours ago
In this case they hadn’t labeled anyone as villains, though. They could have omitted that section entirely.
I happen to agree that labeling them as villains wouldn’t have been helpful to this story, but they didn’t do that.
> It obscures the root causes of why the bad things are happening, and stands in the way of effective remedy.
There’s a toxic idea built into this statement: It implies that the real root cause is external to the people and therefore the solution must be a systemic change.
This hits a nerve for me because I’ve seen this specific mindset used to avoid removing obviously problematic people, instead always searching for a “root cause” that required us all to ignore the obvious human choices at the center of the problem.
Like blameless postmortems taken to a comical extreme where one person is always doing some careless that causes problems and we all have to brainstorm a way to pretend that the system failed, not the person who continues to cause us problems.
> Like blameless postmortems taken to a comical extreme where one person is always doing some careless that causes problems and we all have to brainstorm a way to pretend that the system failed, not the person who continues to cause us problems.
Well, I'd argue the system failed in that the bad person is not removed. The root is then bad hiring decision and bad management of problematic people. You can do a blameless postmortem guiding a change in policy which ends in some people getting fired.
> You can do a blameless postmortem guiding a change in policy which ends in some people getting fired.
In theory maybe, but in my experience the blameless postmortem culture gets taken to such an extreme that even when one person is consistently, undeniably to blame for causing problems we have to spend years pretending it’s a system failure instead. I think engineers like the idea that you can engineer enough rules, policies, and guardrails that it’s impossible to do anything but the right thing.
This can create a feedback loop where the bad players realize they can get away with a lot because if they get caught they just blame the system for letting them do the bad thing. It can also foster an environment where it’s expected that anything that is allowed to happen is implicitly okay to do, because the blameless postmortem culture assigns blame on the faceless system rather than the individuals doing the actions.
agreed, the concept of a 'blameless' post mortem came from airplane crash investigation - but if one pilot crashes 6 commercial jets, we wouldnt say "must be a problem with the design of the controls"
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Blameless postmortems are for processes where everyone is acting in good faith and a mistake was made and everyone wants to fix it.
If one party decides that they don’t want to address a material error, then they’re not acting in good faith. At that point we don’t use blameless procedures anymore, we use accountability procedures, and we usually exclude the recalcitrant people from the remediation process, because they’ve shown bad faith.
> Well, I'd argue the system failed in that the bad person is not removed.
This is just a proxy for "the person is bad" then. There's no need to invoke a system. Who can possibly trace back all the things that could or couldn't have been spotted at interview stage or in probation? Who cares, when the end result is "fire the person" or, probably, "promote the person".
I think as an employer you would prefer not to hire another person that is not productive.
Your customers would prefer to have the enterprise doing stuff rather than hiring and firing.
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> There’s a toxic idea built into this statement: It implies that the real root cause is external to the people and therefore the solution must be a systemic change.
Not necessarily, although certainly people sometimes fall into that trap. When dealing with a system you need to fix the system. Ejecting a single problematic person doesn't fix the underlying problem - how did that person get in the door in the first place? If they weren't problematic when they arrived, does that mean there were corrosive elements in the environment that led to the change?
When a person who is a cog within a larger machine fails that is more or less by definition also an instance of the system failing.
Of course individual intent is also important. If Joe dropped the production database intentionally then in addition to asking "how the hell did someone like him end up in this role in the first place" you will also want to eject him from the organization (or at least from that role). But focusing on individual intent is going to cloud the process and the systemic fix is much more important than any individual one.
There's also a (meta) systemic angle to the above. Not everyone involved in carrying out the process will be equally mature, objective, and deliberate (by which I mean that unfortunately any organization is likely to contain at least a few fairly toxic people). If people jump to conclusions or go on a witch hunt that can constitute a serious systemic dysfunction in and of itself. Rigidly adhering to a blameless procedure is a way to guard against that while still working towards the necessary systemic changes.
Often institutions develop fundamental problems because individuals gradually adjust their behaviors away from the official norms. If it goes uncorrected, the new behavior becomes the unofficial norm.
One strategy for correcting the institution is to start holding individuals accountable. The military does this often. They'll "make an example" of someone violating the norms and step up enforcement to steer the institutional norms back.
Sure it can feel unfair, and "everyone else is doing it" is a common refrain, but holding individuals accountable is one way to fix the institution.
I agree with most of what you said but i'd like to raise 2 points
1) the immediate action _is more important immediately_ than the systemic change. We should focus on maximizing our "fixing" and letting a toxic element continue to poison you while you waste time wondering how you got there is counterproductive. It is important to focus on the systemic change, but once you have removed the person that will destroy the organization/kill us all.
2) I forgot. Sorry
I suppose that depends on context. I think it's important to be pragmatic regarding urgency. Of course the most urgent thing is to stop the bleeding; removing the bullet can probably wait until things have calmed down a bit.
If Joe dropped the production database and you're uncertain about his intentions then perhaps it would be a good idea to do the bare minimum by reducing his access privileges for the time being. No more than that though.
Whereas if you're reasonably certain that there was no intentional foul play involved then focusing on the individual from the outset isn't likely to improve the eventual outcome (rather it seems to me quite likely to be detrimental).
> how did that person get in the door in the first place?
is answered by:
> any organization is likely to contain at least a few fairly toxic people
Exactly. The above comment is an example of the kind of toxic blameless culture I was talking about: Deflecting every problem with a person into a problem with the organization.
It’s a good thing to take a look at where the process went wrong, but that’s literally just a postmortem. Going fully into blameless postmortems adds the precondition that you can’t blame people, you are obligated to transform the obvious into a problem with some process or policy.
Anyone who has hired at scale will eventually encounter an employee who seems lovely in interviews but turns out to be toxic and problematic in the job. The most toxic person I ever worked with, who culminated in dozens of peers quitting the company before he was caught red handed sabotaging company work, was actually one of the nicest and most compassionate people during interviews and when you initially met him. He, of course, was a big proponent of blameless postmortems and his toxicity thrived under blameless culture for longer than it should have.
Of course. I actually think that "we did everything we reasonably could have" or "doing more would be financially disadvantageous for us" are acceptable conclusions for an RCA. But it's important that such a conclusion is arrived at only after rigorously following the process and making a genuine high effort attempt to identify ways in which the system could be improved. You wouldn't be performing an RCA if the incident didn't have fairly serious consequences, right?
It could also well be that Joe did the same thing at his last employer, someone in hiring happened to catch wind of it, a disorganized or understaffed process resulted in the ball somehow getting dropped, and here you are.
> Ejecting a single problematic person doesn't fix the underlying problem - how did that person get in the door in the first place? If they weren't problematic when they arrived, does that mean there were corrosive elements in the environment that led to the change?
This is exactly the toxicity I’ve experienced with blameless postmortem culture:
Hiring is never perfect. It’s impossible to identify every problematic person at the interview stage.
Some times, it really is the person’s own fault. Doing mental gymnastics to assume the system caused the person to become toxic is just a coping mechanism to avoid acknowledging that some people really are problematic and it’s nobody’s fault but their own.
On the contrary. It's all too easy to dismiss as being the fault of a fatally flawed individual. In fact that's likely to be the bias of those involved - our system is good, our management is competent. Behead the sacrificial lamb and be done with it. Phrases such as "hirinng is never perfect" can themselves at times be an extremely tempting coping mechanism to avoid acknowledging inconvenient truths.
I'm not saying you shouldn't eventually arrive at the conclusion you're suggesting. I'm saying that it's extremely important not to start there and not to use the possibility of arriving there as an excuse to shirk asking difficult questions about the inner workings and performance of the broader organization.
> Doing mental gymnastics to assume the system caused the person to become toxic
No, don't assume. Ask if it did. "No that does not appear to be the case" can sometimes be a perfectly reasonable conclusion to arrive at but it should never be an excuse to avoid confronting uncomfortable realities.
> There’s a toxic idea built into this statement: It implies that the real root cause is external to the people and therefore the solution must be a systemic change.
It's both obviously. To address the human cause, you have to call out the issues and put at risk the person's career by damaging their reputation. That's what this article is doing. You can't fix a person, but you can address their bad behavior in this way by creating consequences for the bad things.
Part of the root cause definitely is the friction aspect. The system is designed to make the bad thing easier, and when designing a system you need the good outcomes to be lower friction.
> This hits a nerve for me because I’ve seen this specific mindset used to avoid removing obviously problematic people, instead always searching for a “root cause” that required us all to ignore the obvious human choices at the center of the problem.
The real conversations like that take place in places where there's no recordings, or anything left in writing. Don't assume they aren't taking place, or that they go how you think they go.
> Like blameless postmortems taken to a comical extreme where one person is always doing some careless that causes problem
Post-mortems are a terrible place for handling HR issues. I'd much rather they be kept focused on processes and technical details, and human problem be kept private.
Dogpiling in public is an absolutely awful thing to encourage, especially as it turns from removing a problematic individual to looking for whoever the scapegoat is this time.
The prior is stating an extreme case, eg "comical extreme".
One problem is that if you behave as if a person isn't the cause, you end up with all sorts of silly rules and processes, which are just in place to counter "problematic individual".
You end up using "process" as the scapegoat.
I agree, but in this hypothetical situation the HR part needs to happen, despite the fact that most people don't want to be the squeaky wheel that explicitly starts pointing fingers..
It's way too easy to pretend the system is the problem while sticking your head in the sand because you don't want to solve the actual human problem.
Sure, use the post mortem to brainstorm how to prevent/detect/excise the systematic problem ("How do we make sure no one else can make the same mistake again"), but eventually you just need to deal with the repeat offender.
People don’t really understand what this stuff means and create fucked up processes.
In a blame focused postmortem you say “Johnny fucked up” and close it.
When you are about accountability, the responsible parties are known or discovered if unknown and are responsible for prevention/response/repair/etc. The corrective action can incorporate and number of things, including getting rid of Johnny.
This hits the nail on the head. I liken it to a scale or ladder, each rung representing a new level of understanding:
1) Basic morality (good vs evil) with total agency ascribed to the individual
2) Basic systems (good vs bad), with total agency ascribed to the system and people treated as perfectly rational machines (where most of the comments here seem to sit)
3) Blended system and morality, or "Systemic Morality": agency can be system-based or individual-based, and morality can be good or bad. This is the single largest rung, because there's a lot to digest here, and it's where a lot of folks get stuck on one ("you can't blame people for making rational decisions in a bad system") or the other ("you can't fault systems designed by fallible humans"). It's why there's a lot of "that's just the way things are" useless attitudes at present, because folks don't want to climb higher than this rung lest they risk becoming accountable for their decisions to themselves and others.
4) "Comprehensive Morality": an action is net good or bad because of the system and the human. A good human in a bad system is more likely to make bad choices via adherence to systemic rules, just as a bad human in a good system is likely to find and exploit weaknesses in said system for personal gain. You cannot ascribe blame to one or the other, but rather acknowledge both separately and together. Think "Good Place" logic, with all of its caveats (good people in bad systems overwhelmingly make things worse by acting in good faith towards bad outcomes) and strengths (predictability of the masses at scale).
5) "Historical Morality": a system or person is net good or bad because of repeated patterns of behaviors within the limitations (incentives/disincentives) of the environment. A person who routinely exploits the good faith of others and the existing incentive structure of a system purely for personal enrichment is a bad person; a system that repeatedly and deliberately incentivizes the exploitation of its members to drive negative outcomes is a bad system. Individual acts or outcomes are less important than patterns of behavior and results. Humans struggle with this one because we live moment-to-moment, and we ultimately dread being held to account for past actions we can no longer change or undo. Yet it's because of that degree of accountability - that you can and will be held to account for past harms, even in problematic systems - that we have the rule of law, and civilization as a result.
Like a lot of the commenters here, I sat squarely in the third rung for years before realizing that I wasn't actually smart, but instead incredibly ignorant and entitled by refusing to truly evaluate root causes of systemic or personal issues and address them accordingly. It's not enough to merely identify a given cause and call it a day, you have to do something to change or address it to reduce the future likelihood of negative behaviors and outcomes; it's how I can rationalize not necessarily faulting a homeless person in a system that fails to address underlying causes of homelessness and people incentivized not to show empathy or compassion towards them, but also rationalize vilifying the wealthy classes who, despite having infinite access to wealth and knowledge, willfully and repeatedly choose to harm others instead of improving things.
Villainy and Heroism can be useful labels that don't necessarily simplify or ignorantly abstract the greater picture, and I'd like to think any critically-thinking human can understand when someone is using those terms from the first rung of the ladder versus the top rung.