Article by John Allspaw on Blameless Postmortems in Etsy with key takeaway:
This cycle of name/blame/shame can be looked at like this:
- Engineer takes action and contributes to a failure or incident.
- Engineer is punished, shamed, blamed, or retrained.
- Reduced trust between engineers on the ground (the “sharp end”) and management (the “blunt end”) looking for someone to scapegoat
- Engineers become silent on details about actions/situations/observations, resulting in “Cover-Your-Ass” engineering (from fear of punishment)
- Management becomes less aware and informed on how work is being performed day to day, and engineers become less educated on lurking or latent conditions for failure due to silence mentioned in #4, above
- Errors more likely, latent conditions can’t be identified due to #5, above
- Repeat from step 1