Last week, Owen Thomas wrote a flattering article over at Business Insider on how we handle errors and mistakes at Etsy. I thought...
Having a Just Culture means that you’re making effort to balance safety and accountability. It means that by investigating mistakes in a way that focuses on the situational aspects of a failure’s mechanism and the decision-making process of individuals proximate to the failure, an organization can come out safer than it would normally be if it had simply punished the actors involved as a remediation.
This idea of digging deeper into the circumstance and environment that an engineer found themselves in is called looking for the "Second Story". In Post-Mortem meetings, we want to find Second Stories to help understand what went wrong.
We accept that there is always a discretionary space where humans can decide to make actions or not, and that the judgement of those decisions lie in hindsight.
We accept that the Fundamental Attribution Error is also difficult to escape, so we focus on the environment and circumstances people are working in when investigating accidents.