Writing the article on how a blameless culture can go wrong sparked some interesting discussions. Many people agreed with the points made in the article. Some did not. But all agreed that blamelessness is a critical aspect of a well-functioning organisation.

But why? What makes a blameless culture so important? And why is it so hard to get it right?

Toxic culture of blame

As with all the problematic things in this world, it starts with people. We are wired to blame others. Our primitive reptilian brains evolved to hunt animals in the savanna and are not particularly great at dealing with nuances. We like simple solutions.

Flawed human nature

When faced with issues, we tend to attribute other people’s mistakes to their traits (like laziness and carelessness) and not to external factors. Of course, it does not apply to ourselves. I’m obviously very smart and hard-working, so if something bad has happened, it was surely not my fault. Right? Someone else has to be responsible! Someone else is to be blamed!

And how does a reptilian brain react to being blamed? Humbly accepts guilt and promises to improve? Of course not. It becomes defensive, avoids responsibility and tries to push the blame on someone else.

See how this escalates? Behavioural patterns that were useful when hunting dinosaurs are not a particularly good foundation for building efficient engineering organisations.

The slippery slope of blame

Blaming leads to more blaming. Culture quickly gets toxic. People are running in defensive mode, trying to avoid responsibility for anything important, as it means trouble and being put in the spotlight. Systemic issues remain unresolved, as everyone is focusing on finding scapegoats and shifting the blame. No deep issues analysis, no lessons learned. Just throw the scapegoat aboard and continue.

Silenced by fear

But perhaps the most dangerous result of the blame culture is silence. Being afraid of blaming people starts hiding problems. Status reports are always green, metrics are gamed, and issues are swept under the carpet. To avoid getting in trouble, people present you with the falsified facade of reality. Underneath it, issues accumulate until the facade collapses. But then, it’s usually too late to act. You’ve been fooled in your ivory tower.

That’s the main reason why totalitarian, centrally-managed regimes are so dysfunctional. If you risk going to the Gulag for not meeting unrealistic factory production targets, you will make sure the targets are met. Even if it means falsifying the production reports or compromising on quality.

How to build a blameless culture

To create and maintain a blameless culture, you need to put in a lot of effort. It’s not easy to avoid blaming, and it is even more difficult to still keep high standards and accountability.

Lead the way

The first step to making the world a better place is to start with yourself. Be a role model on how to deal with failures. Openly admitting to your own mistakes and sharing lessons learned sets a good example for your team. It shows them that mistakes happen, and will encourage them to be more open about theirs.

Make it a habit

Most people do not spontaneously share their failings. You should create a space, let’s say, a monthly “Lessons Learned” session, where teams openly share their mistakes and failures. Proactively drive those discussions to ensure they focus not on people’s mistakes but on fully understanding the root causes, mitigations, and lessons learned.

Make sure that lessons learned are an obligatory part of every Incident Management. A well-functioning, blameless post-mortem can be your most powerful tool to identify technical debt and shape the blameless culture in the organisation.

Production incidents do happen, but what makes the organisation outstanding is how they are handled.

Focus on fixing the system.

When discussing the incident, try to remove people from the equation. People make mistakes all the time, and a well-designed system should be prepared for that.

When analysing the issue, ask yourself the question, “What do I, as a manager, do differently so that such an issue does not happen again in the future?“. Don’t confuse it with self-blaming! Self-blaming is just another form of toxic emotion. This question is meant to put you in your analytical shoes and allow you to see the bigger picture of where the process has failed.

Be persistent, and your system will gradually grow to be more resilient and resistant to human errors.

Don’t compromise on standards

Blamelessness, left unchecked, tends to drift towards the culture of avoidance. Where “lack of blaming” is a convenient excuse for lack of accountability and avoidance of tough conversations.

A proper blameless culture requires a relentless pursuit of issues and a disciplined analysis of their root causes. Detached from particular people’s “blame” but by that, even more, focused on constant challenging of the status quo and not accepting easy solutions.

It’s ok to fail

The goal of a blameless culture is to accept that failures will happen.

Humans will fail - that is one thing we should be certain of. Humans can be tired, stressed, and not have a good day - the question we should be asking is how we improve the environment so that we can reduce the chance of a human making an error, and if an error is made, make it a learning opportunity.

The solutions to your organisation’s problems are more likely to be found by examining what’s wrong with your systems than by examining what’s wrong with your employees.