The Culture and Incidents cluster

How organisations learn, or fail to, from what goes wrong.

Why these together

Westrum classifies the culture. Edmondson names the precondition. Blameless Retros and Just Culture are the practices. Dekker's New View is the deeper claim. The Iceberg explains what leaders do not see. Five Whys is the prompt for the conversation. Five Dysfunctions names the predictable patterns of team failure. Cognitive Load is what culture work protects in the end.

Pattern Westrum's Typology Three kinds of organisational culture, distinguished by how information flows. Pathological hoards it. Bureaucratic routes it. Generative shares it.
Principle Psychological Safety The shared belief that you can speak up, ask questions, admit mistakes, and disagree without being punished or humiliated.
Principle Blameless Retrospectives When something goes wrong, look at the system that allowed it, not the person who triggered it.
Saying Just Culture A culture that holds people accountable for the work they did, while looking honestly at the system that shaped the choices they had.
Saying The New View (Dekker) Human error is not a cause of failure. It is a symptom of trouble deeper in the system.
Saying The Iceberg of Ignorance Most of the problems frontline workers know about never reach leadership. The proportion grows the further up you go.
Saying The Five Whys Ask "why" five times to get past symptoms and find the underlying cause.
Saying Five Dysfunctions of a Team Teams fail in five layered ways: absence of trust, fear of conflict, lack of commitment, avoidance of accountability, and inattention to results.
Principle Cognitive Load The mental effort needed to understand or change a system. There is a fixed budget per person and per team.