Blameless post-mortems and a just culture (2012)

This climate of fear made me absolutely miserable. To the point that I have vowed never to be an employee again. I'm not spending 8h a day in an environment where the thought police is breathing down my neck. I'd rather beg on the streets.

Sounds like some one had done a diversity course and missed the point, to be kind. There are other less charitable conclusions that could be drawn.

sounds like a horrible place to work anyway, blameless postmortems aside.

Because the psychological Traits and Needs of all humans are not the same.

Most people who build teams have a sense of their own Needs and Traits and pick strategies/team members that align/compensate.

https://en.wikipedia.org/wiki/Revised_NEO_Personality_Invent...

https://en.wikipedia.org/wiki/Maslow%27s_hierarchy_of_needs

There is a distribution of Traits/Needs that you need to be aware of within any population, group, team etc.

If you are not aware of those variations and randomly create groups and try to impose strategy, what works and fails will always remain mysterious.

And then Lewis would be gone and we would just be losers.

More than 4 decades later, none of the other manufacturers come close to Toyota still. Why?

Because the change is one in how you understand the world. This is really hard to do, particularly as an organisation. It needs to reinvent yourself from scratch. It means killing your org to live again.

The org will fight it. People that were favored will lose power and standing. They will fight it. Things will get worse before getting better. They will fight it. It will need different way to count success. That will be used against it. It will need new way to trust. They will say it is laxist.

Said otherwise: the current structure work good enough. There is not enough reward and competitive pressure to make the huge opportunity cost of change an accepted strategy.

You can apply that model of change infinitely. Ask yourself why we have not seen huge swath of the web move into Elixir as an example.

They also have a budget of close to $500 million, which can't hurt. Ferrari and Red Bull are the only teams that come close to that.

Fourth largest budget is Renault at almost $200 million less.

We'll see if they continue to stack up with the $175 million budget cap that's coming in 2021.

It's not a secret. Many other organizations (not in F1, by your description) operate this way. It's well understood, but...

> Why aren't more teams copying this?

... everyone on the team needs to buy in to this approach. One selfish team member can slowly ruin the whole thing.

The uncomfortable reality of these cultures is that when someone in the culture is not truly committed, or is putting their self-interest ahead of the team, they need to be removed. A lot of leaders are not strong enough to recognize that and take action.

Drivers will always be pitted against their teammate though. F1 is technically a team sport, but the real judgement for the drivers is how well they compare against their teammate. Each driver wants to win, that's why they compete.

It doesn't have to be a dying company. Many companies that try to transition from startup -> small company -> medium company -> megacorp tend to run into periods of change and insanity in every one of those transitions. I suspect its one of the reasons why most companies die out at some point: the failure to focus on product and focusing instead on politics. Teams turtle down, avoid responsibility (i.e. blame) at every opportunity, the product turns to shit as nobody wants to move a muscle in case anything breaks.

If anyone knows how well it applies to this situation, please do tell me!

For how to do it... there is a community at https://www.learningfromincidents.io/ trying to help.

The consensus so far is to test waters and do some "in parallel", if necessary rogue-ish. The output is so superior in term of learning that you may then use this result as a trojan horse.

You need to carry your water.

The core of the philosophy is assuming people come to work to do a good job, and when they don't do a good job, there are reasonable explanations that involve people making locally rational decisions. The goal is to make the system stable in a way that making locally rational decisions translates to globally good decisions.

After this incident we can say, they clearly violated this rule. They cut corners. However, we have no clear view of all the incidents they prevented in the past because they violated that rule. We cannot see that there were twenty other times when violating this rule in exactly this way was exactly what kept things working.

This is the nature of hindsight bias. After the fact, it's completely obvious exactly which of the conflicting rules should have been followed. It is obvious because we now know the outcome.

If you're in the thick of an incident making high-pressure, and high-consequence decisions under duress there is no way to actually predict the outcomes that will become obvious only after-the-fact.

Taking a balanced approach is good universal advice for everything. But in this context, it misses the point of blameless retros.

Our cultural norm is to stop investigations once we find the culprit who cut-corners. The consequences of that systemic habit are that we fail to learn and understand all of the complexity that actually contributed to the failure. We cut short our own learning. What's more, we also effectively teach everyone in the system to conceal or withhold their full understanding in the next incident. So we learn only the most shallow details about what actually happened for this incident, and we suppress what we might learn in the next incident.