It’s a story about moving from a culture of blame – and the costs of a culture of blame – to a culture of blamelessness. What does that look like?
Problems with a culture of blame: accountability means finding a scapegoat, which means that people fear sharing what they know because the repercussions are so extreme. And in any complex system, it’s hard to understand what is going on and how things will interact. Stuff will happen – when people don’t share what they know, it can’t be learned from. When people are fired because they did their best but were operating with incomplete knowledge and something broke as a result, organizational knowledge is lost.
The main process outlined in the book for a blameless culture is the blameless postmortem. People share what happened and what they know, and are not judged (or allowed to judge themselves) with the benefit of hindsight. Then things that need to be followed up on can be identified.
Really the main message I took from the book is that blamelessness is necessary for a culture of accountability – because without blamelessness, it’s not safe for people to share the full details of what happened, which means no-one really knows what did happen.