““When these accidents affect our customers, we seek to understand why it happened. The root cause is often deemed to be human error, and the all too common management response is to “name, blame, and shame” the person who caused the problem.† And, either subtly or explicitly, management hints that the person guilty of committing the error will be punished. They then create more processes and approvals to prevent the error from happening again. Dr. Sidney Dekker, who codified some of the key elements of safety culture and coined the term just culture, wrote, “Responses to incidents and accidents that are seen as unjust can impede safety investigations, promote fear rather than mindfulness in people who do safety-critical work, make organizations more bureaucratic rather than more careful, and cultivate professional secrecy, evasion, and self-protection.” These issues are especially problematic in the technology value stream—our work is almost always performed within a complex system, and how management chooses to react to failures and accidents leads to a culture of fear, which then makes it unlikely that problems and failure signals are ever reported. The result is that problems remain hidden until a catastrophe occurs.””
