Comparison
Hindsight biasvsJust culture
Hindsight bias
reading the timeline afterwards, the cause was obvious, and at 02:00 it had not been obvious to anyone.
The tendency to see a past outcome as having been predictable once you know it happened. It is the main thing that corrupts incident reviews, because it converts a reasonable decision made with partial information into an apparent mistake. The countermeasure is to reconstruct what was actually visible at each moment and to keep asking why the wrong action looked right, rather than why the right one was not taken.
Full entry →Just culture
the engineer who ran the command explained exactly what they saw, because nothing bad was going to happen to them for it.
A culture that separates accountability for outcomes from blame for individuals, so that people report what actually happened. It is not the absence of accountability, which is the standard misreading of 'blameless': the team still owns fixing the system, and repeated reckless behaviour is still addressed. What it removes is the incentive to be vague, which is the single largest source of lost information after an incident.
Full entry →