Comment by Aurornis
12 hours ago
> 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"
So what do they say actually in aviation? There was a pilot suicide with the whole plane Germanwings Flight 9525, I find it more important the aviation industry did regulatory changes than the fact that (probably) "they blamed the pilot".
I think there are too many people that actually like "blaming someone else" and that causes issues besides software development.
I hope that the pilot responsible was fired and got his license revoked!