qualitylab

the station

Blameless PostMortems and a Just Culture

tier IV/2012/Etsy Code as Craft

https://jaytaylor.com/notes/node/1498058768000.html

Method

none stated

Population

none stated

What it does not show

Presents no data: no incident counts, no before-and-after comparison, no measurement of whether the practice reduced repeat incidents or increased reporting. A foundational statement of rationale, importing its framework from safety science in aviation and healthcare rather than from any software study.

John Allspaw

Argues that letting engineers give a full account “without fear of punishment or retribution” surfaces the real mechanisms behind a failure rather than stopping at human error, framed using Dekker’s Just Culture and Hollnagel’s treatment of human error as an effect rather than a cause.

Tier IV: Practitioner essay making an argument and describing one company’s practice, with no measurement, comparison group or outcome data. Sourcing note: the canonical Etsy page returned 403; a full-text mirror was used and that substitution is disclosed here rather than hidden.

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