Beyond Blame: Learning From Failure and Success

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

Table of Contents

Chapter 1. Executive Action
Chapter 2. Dealing with the Root Cause
Chapter 3. Operator Error
Chapter 4. The Bad Apples
Chapter 5. Holding to Account
Chapter 6. Why Things Break
Chapter 7. Who’s to Blame?
Chapter 8. Trade-offs
Chapter 9. Reliable Errors (or Reliably Error-Prone)
Chapter 10. The Second Victim
Chapter 11. The Downside of Blame
Chapter 12. Paradigm Shift
Chapter 13. Executive Support
Chapter 14. Complex, Adaptive Systems
Chapter 15. The Learning Review
Chapter 16. The Timeline
Chapter 17. The Town Hall
Chapter 18. The Learning Review Framework