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Indeed. Punishing people for making human mistakes causes them to hide them, feel ashamed, and not highlight issues that may affect others. Aviation has fostered (very specifically) an open culture of inquisition to errors: it's assumed that if one qualified pilot made a mistake, any qualified pilot could make the same mistake under the same circumstances. If anything, you're actively encouraged to report things that are either confusing, or situations when you nearly made a mistake – the gliding club I spent a lot of time at in the past explicitly encouraged issues to be reported and put them in their monthly newsletter. Root cause analysis is a wonderful thing, and sometimes very convoluted and interesting.

I'm sure the outcome of this event will probably be a technical mitigation of some variety to attempt to stop it happening again.



Interesting that programming went in the same direction. Blameless post-mortems etc.


This move was championed in the industry by John Allspaw, then CTO of Etsy, around 2010. I am under the impression that he introduced the idea of blameless post mortems but I could be misremembering.




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