Beyond Blame: Learning From Failure and Success

by Dave Zwieback

Failure is inevitable. Our increasingly complex world demands that we continuously learn from failures (and successes) in order to survive and thrive. And yet, our learning is too often undermined. We construct biased but comfortable stories, which often feature a simple, single "root cause"--a villain, someone to take the blame. Having done that, we short-circuit the possibility of developing any deeper understanding of the complex systems we work with. With this common approach, our systems will become more fragile and drift into failure.

In this concise and entertaining book, I.T. veteran Dave Zwieback describes an incident that threatens the very existence of a large financial institution, and the counterintuitive steps its leadership took to stop the downward spiral. Their novel approach is grounded in proven concepts from complexity science, resilience engineering, human factors, cognitive science, and organizational psychology. It allows us to identify the underlying conditions for failure, and make our systems (and organizations) safer and more resilient.

- Get a clear understanding of the downside of blame
- Learn how to identify (and counteract) cognitive biases in groups
- See how organizations can determine the real root cause of problems
- Establish real accountability with your organization
- Use the Learning Review Framework to fully learn from failures of complex systems
- Find practical insights and tips for moving beyond blame in your own organization

Genres: Business, Leadership, Management, Engineering, Technology, Nonfiction

75 pages, Paperback

First published October 29, 2015

About the author

Dave Zwieback has been working with complex, mission-critical I.T. services and teams for three decades. His career spans small high-tech startups, non-profits, and behemoth engineering, financial services, and pharmaceutical firms.

Dave is a trusted advisor & mentor at Mindweather LLC, which offers extraordinary support for tech leaders.

Reviews

[Leena S N · Rating 4 out of 5]

Small but lovely book talking about why root causes fail by stopping at blames and how organisations stop learning from such failures.

It was interesting to see the reference to Cynefin model, for complexity and learning models.

[Pavel · Rating 4 out of 5]

The book describes a pretty typical outage in a large organization, focusing on how to analyze root cause without blaming people. Four stars is because characters look over-typical. The engineer was fired for “causing an emergency” even it was obvious that he didn’t cause it, the atmosphere in the Company was very toxic but then over a few pages and citations of Kanneman’s book it overturned 180 degrees.

Doubtful, but okay.

[Tom · Rating 5 out of 5]

It is really a very good read, with some very useful insights. The way it is written is enabled me very fast to identify myself with the story, this will happen for everyone who worked in NW engineering and was hit by bug - yes Cisco I am looking at you.
It also encourages you to dive a little bit deeper into the topic of cognitive biases and how they affect us. Really recommended small book.

[Esraa · Rating 5 out of 5]

I love the book , As a computer engineer , I can definitely relate to the network outage.
We need to look beyond blame and shame and see what we can learn ,

[Sandro Manke · Rating 5 out of 5]

Finally came around to read this one and I think its a great intro to that topic even with further reading attached. Very much worth reading if that topic is of interest :)

[Jan-Willem Van · Rating 5 out of 5]

Kort verhaal waarom je verder moet kijken dan een persoon bij het inventariseren van problemen.

[BRIAN C NEWMAN · Rating 4 out of 5]

Short and illustrated through a storyline that takes you through a situation not unlike any in software development today.

[Lauren Villarreal · Rating 5 out of 5]

Incredibly clever fictional story which explains how to shift from the process of blame in the workforce to failing forward.

[Yiorgos Adamopoulos · Rating 3 out of 5]

Interesting, fast read, especially if you're in one of the most thankless professions in the world.

[Jan-Joost Bouwman · Rating 3 out of 5]

Never mind the format, this booklet introduces some important concepts and ideas. The blameless postmortem in itself is already important, but it also touches on a couple of interesting other ideas that lay at the basis of the blameless postmortem. Definitely will dollow up on some further reading. And will use the checklist in the end to have a look at our own postmortem process.
Yes, the story is not brilliant. I didn't get at all why the chapter about Linda's son was in there (or even what the point of her background was, where the other characters didn't have auch a baxkground scetch). And the switch Raj made from undisxlosing to advocate seemed farfetched. But he, that is ok. The message atands.

[Dak · Rating 5 out of 5]

A must-read for root cause analysis ... Which all too often stops at "found a scapegoat"

So you've been in a blame and shame culture, and you know it can be better. Here's a framework that expands on some very useful work published in HBR.

I can't wait to take it for a spin. It is consistent with the best root cause analyses I've been invoked in, and the worst.

[Jon · Rating 3 out of 5]

Nearly the entire book is in faux-case-study narrative. This book would have been a lot more useful if it had broken narrative to discuss the concepts at play rather than leave it up to a mix of reader deduction and insert-words-into-characters' mouths. There are certainly some great principles here, but needs a LOT more depth.

[Ivan Dimitrov · Rating 2 out of 5]

Pretty short, does not go into character building at all. Looks like a conference talk written as a book. At the end there is a short Appendix with a checklist on what/how to do post-mortems, that I've copy/pasted to my internal policy.

[Jens Rantil · Rating 3 out of 5]

Not so many surprises. I got what I expected. A great book for 1) managers that work in a toxic organization environment or 2) general people working in toxic american organizations. I believe we have less of these toxic company cultures in Sweden.

[Travis Volker · Rating 2 out of 5]

A fair concept regarding blame free debriefs and no consequence as long as you give a full honest account of everything that occurred. I didn't care for the story telling. It's clunky.

[Mike Fiedler · Rating 5 out of 5]

Short and sweet narrative that explores a scenario from multiple angles. Introduces some new terminology to handle communication about technical situations that have previously been confusing.

[Alev Haddadieh · Rating 5 out of 5]

Author has introduced a very useful framework than can be applied to any IT project. I have actually enjoyed the philosophical approach to the story telling.