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Hi.
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My name is Rein Henrichs.
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My talk is about blame and blameless postmortems: where we went wrong and what we can do about it.
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Blameless postmortems originated from a talk by John Allspaw, and the basic idea was that when an incident happens, if we punish the individuals involved, we not only hurt those people but also make them less likely to assist in the future.
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This ultimately makes it harder to learn from the incident. All of these statements are true, so why am I suggesting that a blameless culture is making us less resilient?
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The reason is that those attempting to cultivate a blameless culture often seek to avoid blame, assuming that this is the essence of being blameless. Unfortunately, they do not fully comprehend what blame entails.
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This misunderstanding leads to counterproductive behaviors that have become entrenched as what blamelessness represents today.
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One particularly concerning behavior is the notion that we avoid asking 'who' questions under the premise of being blameless. A historical example can be found in a blog post by PagerDuty, which stated that we want to understand how a mistake was made rather than identifying who made the mistake.
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While I understand the origin of this perspective—considering that knowing who was responsible can lead to punishment—it is problematic. By ignoring attribution, we not only miss a chance to learn but also dismiss necessary insights.
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Attribution, when understood properly, is essential for learning and improvement. For instance, John Allspaw's original blog post emphasized the significance of attribution for learning, as it allows us to gain insights from those who were present during incidents.
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We need to know what actions were taken, what effects were observed, and what expectations and assumptions were held by those involved. In general, we must understand how individuals perceived the unfolding events.
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Attribution helps us gather vital information from those who were directly involved, allowing us to learn effectively. This concept aligns with Sydney Dekker's idea of 'getting in the tunnel' with the worker.
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Rejecting attribution also implies rejecting the opportunity to learn. Fortunately, there exists an alternative: we can maintain our focus on attribution and learning while ensuring that knowledge of who did something does not automatically lead to punishment.
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It's crucial to explore the relationship between attribution and sanction, understanding that the cognitive process leading from attribution to sanction is blame itself. This process illustrates how attribution can metamorphose into blame, ultimately resulting in potential punishment.
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What we genuinely seek is not the absence of blame, but rather a way for attribution to result in an appropriate level of sanction—usually none—in circumstances where social norms dictate that punishment would not be warranted.
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Thus, if blame operates correctly according to our social norms, we won't see excessive sanctions applied.
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The question we must address is how to ascertain who contributed to an incident without resorting to punishment. To explore this, I propose two strategies...
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First, we can craft an environment that diminishes harmful blaming behaviors. Second, when these behaviors do occur, we need to intervene effectively.
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To accomplish these tasks, we must first cultivate a deeper understanding of what blame is and how it operates, and this exploration will begin with ontology, or the nature and meaning of blame itself.
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According to moral psychology literature, blame constitutes a concrete moral judgment characterized by cognitive and social elements. It refers to specific events rather than mere general moral judgments and is defined by its capacity to influence social behavior.
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This duality of nature raises another question: Why do we blame? What purpose or role does blame serve? The answer lies in the notion that blame facilitates social regulation.
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Crucially, blame operates as a social behavior, which means it also regulates itself. Members of a community can challenge premature or inaccurate expressions of blame, thereby enforcing social norms.
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When these norms are upheld, they slow the process of accusation and punishment. Consequently, to reduce this process, we must develop models that clarify how blame functions.
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The complexities of blame can be summarized as follows: we perceive a stream of events, and when we disapprove of certain occurrences, our brains process that discontent—leading to potential sanctions, which must be justified.
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In many situations, a sanction may not be necessary, but when one is applied, it is crucial to provide justifications for that decision. This inquiry brings us back to moral psychology, which can help elucidate the mechanics behind how we make moral judgments.
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Historically, moral philosophy has explored whether judgments stem from reason or passion. The prevalent model, known as the path model of blame, suggests that we assess various moral dimensions when a negative event occurs...
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This model begins by verifying whether the incident resulted from a norm violation and if so, whether the involved individual intended to violate that norm. If both conditions hold, we seek justification for that behavior. This logical progression leads to the determination of whether sanctions are warranted.
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However, the path model is fundamentally flawed as it implies a linear process, while human cognition is rarely this straightforward.
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Additionally, it largely overlooks the passionate and impulsive aspects of human behavior; blame is often driven by a natural instinct to uphold social values.
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To enhance our understanding of blame, we require a holistic approach that integrates both analytical reasoning and intuitive processes. The parallel processes model proposes that these cognitive processes work together, reinforcing one another...
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This synergy indicates that intuitive judgments may be refined by deliberative reasoning processes when individuals possess the necessary capability and motivation to engage critically.
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Understanding the nuances of how brains function is also vital. For instance, we often fill in gaps in our perceptions, unconsciously inferring missing details related to blame.
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This cognitive phenomenon also influences moral judgments, wherein we tend to implicate a 'villain' even in situations lacking clear wrongdoing.
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This need to identify a offender can lead to unreasonable blame, wherein individuals are punished, sometimes irrationally, when the reality may not warrant such action.
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Furthermore, emotional responses such as anger can arise uncontrollably, leading us to assign blame based on impulsive judgments rather than informed reasoning.
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Consequently, we must consider how to address blame that emerges instinctively in our consciousness, often linked to a perceived necessity to blame.
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Consequently, we can once again consider the two strategies: cultivate contexts that minimize harmful blame and intervene to redirect blame more constructively when it does arise.
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One effective method involves prompting individuals to engage in more deliberate cognitive processing in these blame situations. Studies indicate that those who employ more considered moral reasoning ultimately arrive at better moral conclusions.
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The path model, while flawed, serves as a useful facilitation tool. That model can be viewed as a checklist to highlight opportunities for individuals to engage broader cognitive processing, which can mitigate unjust sanctions.
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By asking about causality, intentions, and potential justifications for actions, we can reduce the likelihood of punishment and retribution.
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In fact, we can leverage our nuanced moral cognition and utilize blame not as a source of punishment, but as a tool for constructive moral communication that reinforces our social norms.
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When social norms are communicated effectively during incidents, the focus shifts to ensuring socially acceptable behavior when sanctions are necessary.
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Effective leaders and facilitators can use this process of blame constructively to delineate how sanctions should function in a manner that discourages harmful blame responses.
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It is essential to establish clear expectations regarding permissible and impermissible behaviors while simultaneously managing sanctions in a thoughtful manner.
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Through mindful intervention, community norms can be upheld while reducing the unintended consequences associated with punishment.
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Blame should be viewed as a natural occurrence that can be effectively channeled within a supportive context, rather than as a phenomenon to be avoided at all costs.
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By fostering an environment where 'who' questions may be asked safely and where sanctions are applied more thoughtfully, we can undermine unjust blame while simultaneously reinforcing social bonds.
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In conclusion, we have a professional and moral obligation to refrain from causing harm and to thoughtfully guide our communities toward constructive engagement with blame.
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By establishing the right contexts and approaching blame with both care and empathy, we can promote healthier interactions and ultimately foster more resilient communities.
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Thank you for your attention. I'd be happy to receive any feedback, so please feel free to tweet at me.