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Blame is the enemy of#

Blame is the enemy of safety. Focus should be on understanding how the system behavior as a whole contributed to the loss and not on who or what to blame for it


@worrydream tweet citing Engineering a Safe World: Systems thinking applied to safety


And a bit more

When trying to understand operator contributions to accidents, just as with overcoming hindsight bias, it is more helpful in learning how to prevent future accidents to focus --not-- on what the operators did "wrong" but on why it made sense for them to behave that way under those conditions