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Principles for learning and review

Blame and accountability

In high-pressure meetings, emotions can run high, and there's a natural tendency to assign blame. But a blame-focused environment often inhibits learning.

Shifting away from a blame culture can be challenging, especially when an incident has visibility across the organization, with executives or senior stakeholders present, but it’s crucial to approach each review with an assumption of good intent.

Being blameless doesn’t mean avoiding names or skirting the problem; it’s about starting from the understanding that everyone involved was trying to do the right thing. When we start with this premise, the conversation shifts from “why did you do this?” to “that action clearly made sense to you — help us understand why.”

If you'd like to go deeper on blameless culture, check out Andrew Guenther from OpenAI's talk on the subject from SEV0!

Accountability in the wake of an incident is about being responsible for recounting what happened, not about assigning fault. Understanding the motivations and decisions of the people directly involved can provide insight, allowing us to turn these lessons into actionable takeaways.

Prevention is not the only outcome

Incidents will happen again. Asking, “how will we prevent this from happening again?” may seem helpful, but it can stifle genuine learning.

Consider a situation where a system feature you didn’t know about behaved unexpectedly and created an unforeseen issue. Whilst addressing it in the moment provides some insight and may prevent a repeat of that specific issue, you’ll still have countless unknowns across other systems. Should you then prioritize a deep dive into every feature? And how many other systems would need the same treatment?

The point isn’t to give up on improvement. Everyone wants better service and happier customers, but it’s essential to accept that not every issue is preventable. Overcommitting to prevention often leads to time-consuming, low-value work with little assurance of payoff.

Focus instead on learning, understanding, and adapting in ways that offer genuine value.