Comparison
Incident reviewvsJust culture
Incident review
you sat down a week later with the timeline and worked out why the wrong dashboard was the obvious one to check.
The structured examination of an incident after it is over, producing a timeline, an understanding and a small number of owned actions. Its purpose is learning, not documentation: a review that produces a file nobody reads and eleven tickets nobody does has cost more than it returned. The best ones spend most of their time on why things made sense to the people involved at the time, because that is where the improvable system lives.
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 →