blameless postmortems and just vs. fair culture

I have been thinking about postmortem processes lately. One of the first articles to popularize the concept was James Allspaw’s blog post in 2012 about Blameless Retrospectives at Etsy. The article’s not just about Blameless Retrospectives, however. Allspaw argues that the approach to retrospectives is part-and-parcel with Etsy’s Just Culture. To Allspaw, there’s a fundamental belief of right intentions that is required in a just culture.

The action made sense to the person at the time they took it, because if it hadn’t made sense to them at the time, they wouldn’t have taken the action in the first place.

The base fundamental here is something Erik Hollnagel has said:

We must strive to understand that accidents don’t happen because people gamble and lose. Accidents happen because the person believes that: …what is about to happen is not possible, …or what is about to happen has no connection to what they are doing, …or that the possibility of getting the intended outcome is well worth whatever risk there is.

Hollnagel’s ideas about why accidents happen led me to read more of his work, including his essay, Just Culture vs. Fair Culture. The essay is worth a read itself, but to summarize Hollnagel:

A Just Culture is an artefact of “blame-and-shame” culture. The Just Culture tries to move away from this basis, but still generally assumes that cause is the result of “human actions, specifically ‘human errors,’” and that consequently “there is clearly a need somehow to protect people from being unjustly blamed for their purported wrongdoings, and even to encourage them to report on such things.”

Fair Culture, in contrast, tries to move away from human action as a cause. Instead, “[t]he notion of a fair culture is rather a consequence of the realization, or if you will the assumption, that things that go right and things that go wrong happen for the same reasons.” Said another way: there’s a degree of luck in outcomes and recognizing that is important in understanding how events played out, particularly in understanding the root cause.

Allspaw and the Etsy approach seems to be a direct descendent of the Just Culture view of the world and is focused almost exclusively on ensuring a safe (and accountable) environment to understand how issues occurred. This was later adopted at Google in their SRE Practices as well.

A blameless retrospective is a huge advancement over blame-and-shame, but it is striking how it only makes sense in a world where we attribute to human action the results. The practices seem to make less sense in a world where it’s accepted that good and bad outcomes occur for the same reasons.

In discussing compliance with protocol, Hollnagel may actually point to the way forward (and which both Etsy and Google seem to have adopted):

Compliance is on the one hand touted as the solution to (all) safety problems, while it on the other is recognized that people have to be flexible and adjust what they do to the conditions. (This is the ETTO paradox: that people are expected to be efficient except when in hindsight they should rather have been thorough.) There is thus a built-in conflict between work-as-imagined, the procedures and the demands to compliance, and work-as-done. A fair culture is one where there is no bias from hindsight. It is simply not fair tacitly to condone what people do and even encourage them to do it, and then blame them if it did not work.

Even though the practices are borne out of a Just Culture, the practices of eliminating the individual and finger-pointing, what Allspaw refers to as the “Second Story”, is an effort to eliminate bias from hindsight, though as he would go on to point out, it’s an ongoing effort:

So what do we do to enable a “Just Culture” at Etsy?

• […]
• 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 Hindsight Bias will continue to cloud our assessment of past events, and work hard to eliminate it.

In all of this I’m left with more questions to ponder and ideas to chew on than answers. Nonetheless, I am excited about these initiatives and seeing them practiced more widely.