A few problems I faced:
- culturally a lack of deeper understanding or care around “safety” topics. Forces that be inherently are motivated by launching features and increasing sales, so more often than not you could write an awesome incident retro doc and just get people who are laser focused on the bare minimum of action items.
- security folks co-opting the safety things, because removing access to things can be misconstrued to mean making things safer. While somewhat true, it also makes doing jobs more difficult if not replaced with adequate tooling. What this meant was taking away access and replacing everything with “break glass” mechanisms. If your team is breaking glass every day and ticketing security, you’re probably failing to address both security and safety..
- related to the last point, but a lack of introspection as to the means of making changes which led to the incident. For example: user uses ssh to run a command and ran the wrong command -> we should eliminate ssh. Rather than asking why was ssh the best / only way the user could affect change to the system? Could we build an api for this with tooling and safeguards before cutting off ssh?