At the end of the day if your intern can take down your production DB, about 5 other things went wrong first to put them in a position to be able to do so.
Systems are complex, and sometimes the holes in the Swiss cheese line up.
Britain's Maritime Accident Investigation Branch (EU rules required members to have such agencies, although I think the UK had several of them before that anyway) published a memorable report where, despite this usual practice they offer zero recommendations.
The accident was basically some guys took a fishing boat out, did a lot of heroin, got into trouble and all died. And there were no recommendations because heroin is already illegal, operating a fishing boat while on heroin is also illegal, so, yeah, we already told you this was a terrible idea, there's nothing to recommend.
Which in the context of incident prevention translates into adapting to what is happening and maintaining the safety profile to prevent the incident.
Half mast sale - less force on the mast, more time to react to things when going solo.
The offending dog's name is still there...
I guess aiming for blameless is as good as it gets sometimes.
There are two important things that make something blameless: phrasing and culture. If you've phrased something in such a way that there's a clear value judgement, your phrasing isn't blameless. And if you're writing in a culture where, no matter how precise the phrasing, the simple existence of a name will make people blame them for what happened, then your culture isn't blameless. Both are required for a blameless post mortem.
Also, think of it this way: no amount of anonymization will prevent the people involved from knowing who did what. If they're privately blaming the person for the incident, it's still not a blameless post mortem.
No amount of verbal wallpaper can fix a broken culture.
Usually it’s work-related, but sometimes the personal stories like this sailing one give a better insight and show real understanding of systematic failings and that they really have the right mindset. Those real world examples speak volumes.
pickpuck•8mo ago
sylens•8mo ago