Laws of Software Engineering · Saying
Saying
The New View (Dekker)
Human error is not a cause of failure. It is a symptom of trouble deeper in the system.
How to use it. When investigating an incident, do not stop at "they pressed the wrong button". Ask why pressing the wrong button was easy, why nothing caught it, why the right button looked the same. The button is the surface. The system is the story.
How it gets misused. Treated as "nobody is ever responsible". The New View is about causation. Accountability is a separate question. Holding people accountable for the work they did and looking at the system that shaped their choices are different conversations. Both are honest, and neither is enough alone.
Related
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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.
Clusters
- The Culture and Incidents cluster - How organisations learn, or fail to, from what goes wrong.