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Comment by thewebcount | Hacker News Reader

How does that square with the need to improve systems so the same problems don't happen again? I get not wanting to put blame on a particular person, group, or cause when it's multi-factorial, but how can you improve if you don't figure out why the failure occurred?

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I’m not the OP, but when I think of “systemic thinking” I think the focus is more on looking at all of the factors involved as part of a holistic model rather than placing blame at the feet of a particular individual or process. You can still identify causes and try to remediate them, but most of the time the remediation shouldn’t be something like “let’s fire Bob for making a mistake/error”, but rather, “Let’s look at all of the events that led up to Bob making that mistake and figure out how we can help him avoid it in the future through a system, process, or people change, or a combination therein”.

That being said, if someone is negligent and consistently does negligent things they should probably be put into a position where their negligence won’t cause catastrophic system failures or loss of life. Sometimes that does mean firing someone.

A big part is acknowledging that the actions that human operators take is largely a result of the environment in which they operate. Typically there are many issues with that environment that be improved and all human operators will benefit.

To give you a more concrete example, it moves the analysis away from "Bob deleted the production database" into a more productive space of "we really shouldn't have a process that relies on any human logging into the production database and running SQL queries by hand, that's prone to human mistake".

That's one of the central questions of the book. But my take is that there are a bunch of ways to answer a "why" question, some more useful than others.

One very common mode is to take a complex causal web, trace until you find a person of low status, and then yell at and/or punish said scapegoat. That desire to blame is a very human approach, but it a) isn't very effective in preventing the next problem, and b) prevents real systemic understanding by providing a false feeling of resolution.

So if we really want to figure out why the failure occurred and reduce the odds of it happening again, we need to give up blame and look at how systems create incentives and behaviors in the people caught up in them. Only if everybody feels a sense of personal safety do we have much chance of getting at what happened and discussing it calmly enough that we can come to real understandings and real solutions.

Thanks for the clarification. This sounds like an interesting book.

The phrasing used on the web site is "Post-accident attribution to a ‘root cause’ is fundamentally wrong." At first glance, it sounds like the author means there is no cause that can be found so you shouldn't try to determine the cause. First they clarify by saying there are many causes not just one. However, this phrasing made me scratch my head:

> The evaluations based on such reasoning as ‘root cause’ do not reflect a technical understanding of the nature of failure but rather the social, cultural need to blame specific, localized forces or events for outcomes.

I don't know what other organizations are like, but where I work, when we do a "root cause analysis," we aren't literally looking for a single cause, despite the name. The "root cause" is almost always that pieces a, b, and c came together in an unexpected way. I can definitely think of places where I worked where they were mostly out to place blame, though, and I guess that's what they were trying to caution against.

I think blame is one way it can go bad, but not the only one. The whole framing of a "root cause" is dangerous, in that it encourages people to look for exactly one thing, and then not look beyond it when they find it. It sounds like your organization does decently in that regard, but they're doing it in spite of the "root cause" frame.

There's a definite difference between blame and cause, and they don't conflict. Blame is for individuals, cause is for systems. While you do need to hold individuals accountable, most of the time you should focus on fixing the system, which is a much more durable fix.

Part of the philosophy is to change the mindset from a “person” perspective to a “process” perspective. I.e., what gaps in the process led to the mishap, not what person caused the mishap.

Organizations that are people dependent rather than process dependent tend to have higher risks of failures.

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