> Now they are the ones who did everything wrong and should be blamed.

Is it possible to develop a blame-free (or at least blame-avoiding) culture that also can still look for root cause problems? I'd like to think so but have never seen such a thing at scale.

This is the question that has been going through my head after I wrote the parent comment.

I have never been in such a situation (at least not one where the stakes were relevant), so take this with a grain of salt. Blaming under these kind of circumstances might arise because the people who do it:

* Either do not have access to the information necessary in order to develop a sufficient understanding of the problem at hand

* Or are incapable of understanding the problem at hand to a sufficient degree (because the project is too big for a single person to grasp or whatever)

So, they resort to assuming some simplifications in order to make everything understandable to them, but these simplifications are likely to be wrong. Consequently, they start blaming people they think to be at fault under their own flawed model of the situation.

A blame-free culture? Explain the situation to such a degree that the decision making around the root cause is easily understandable for everyone. For example, if a bridge fails, there will likely be experts that identify what has caused the failure. If the decision makers for the bridge now say that due to circumstances they disregarded a certain load situation, because x and y and this is an acceptable argumentation (to whoever is judging the situation), there will be less/no blaming as it is now understandable why things have been done that way.

But at a cultural level? I think that this would require everyone to ultimately only judge situations once they have understood the problem at hand. At that point, why do we even talk to each other? Everything we say is based on incomplete information anyways..

You've missed a third bullet point:

* They are capable of understanding the problem, and have access to the information necessary in order to understand the problem, but will advance their career/campaign by pushing their opponent under the bus.

Politicians don't get elected based on objective past results, they get elected based on how well they can spin promises of the future.

And, as the saying goes, you get what you measure.

https://en.wikipedia.org/wiki/Just_culture "Just culture is a concept related to systems thinking which emphasizes that mistakes are generally a product of faulty organizational cultures, rather than solely brought about by the person or persons directly involved. In a just culture, after an incident, the question asked is, “What went wrong?” rather than “Who caused the problem?”. A just culture is the opposite of a blame culture."

Also "Just Culture: Restoring Trust and Accountability in Your Organization" by Sidney Dekker

I believe you're talking about Human Factors which is an entire field of study in complex systems and psychology. The book The Field Guide to Understanding Human Error might be of interest.

I think that single person electorates and direct voting for the executive branch are not exactly helping this situation.

I wonder if it would be batter if the primary power was in the hands of a multi-party, proportionally elected assembly with representation greater the 1 assembly member per a population of 20.000 residents (for both national and local governments) and no executive branch (or perhaps executive branch being experts hired by the assembly). There would certainly be less room to blame here (or at least the blame would be on the entire governing body; which could be voted out proportionally rather then individual representatives).

In general, I want to understand what happened and since most issues have a human component, that often means understanding which human under-performed, how and, ideally, why.

In that sense, I want us to understand where the responsibility for the failure (aka the blame) lies. That’s different from punishing based on any single incident.

You absolutely can have blame without punishment.

The issue is that human interactions are largely based on reputation. If a person is blamed, immediately their reputation suffers. Hence blame=punishment.

As mentioned in other comments, if you are close enough to know and understand then qualifying facts may remove the reputational damage in your mind, and you may fully trust that person to do similar work in future.

But in society wide incidents few of us are that close to the event of concern.

Yes. The NTSB is such a culture.

Yes, it's possible, as long as you are willing to give up democracy. I'm not sure you want to make that trade-off.

Edit: This seems to be negative karma bait, so let me express in clear terms - in a democratic system, all else being equal, a challenger who does play the blame game will prevail over an incumbent, who let a disaster take place on their watch.

I would argue that we would indeed need more democracy (see sibling comment).

The current situation in many of the world’s leading democracies is that representation is abysmal and the democratic process is gamified in such a way as to encourage this kind of blame-game. I’m pretty sure there exists a way to optimize the democratic process in such a way that this blame-game doesn’t happen.

I think this is similar to what happened in Fukushima, where the original architects of the Daiichi plant suggested building a much higher protective wall against tsunamis, but were forced to build a lower wall because such a catastrophic tsunami was deemed too improbable. (Then it came, of course.)

That may or may not be true but as per the article, building standards like that are defined in terms of 1 in 100 or 1 in 1000 year events etc. The years bit in Japan will be defined already in their standard for designing a protection for tsunami events. Now, I don't know what 1 in n years is used but I suspect that it would be 1 in 500 or 1000 years. If a 1 in 10000 years event turns up then the inevitable happens.

So all we have to look up is the standard and the event and compare. Even then you have to design to account for what to do and what happens in the event of your wall's failure and that is probably where things went really wrong.

You could always read things like this: https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1710-Repor...

Yeah, exactly. The thing is, where do you draw the line of what is statistically so unlikely that you can deem it improbable?

If we run multiple different climate models through some sort of Monte Carlo simulation, I suppose each model would output a different probability of such an event occuring. In the case where all models predict a very low probability, it may be easy to say that it is unlikely. But what if two predict a very low and one predicts a low probability? Is this now applicable and should we build to be able to sustain such an event?

These are hard questions and I currently do not see any way to get better data for the future as the different models still do not agree in many points

In that case it could be interesting to plan for future reinforcements, and continue to run the simulations as time passes and the situation evolves.

I don't know if it's due to models and computing environments not being stable enough, but I haven't heard of such a thing, while it is the obvious thing to do: even without reinforcing a dam, you could tell when it becomes dangerous to operate it.

> In that case it could be interesting to plan for future reinforcements, and continue to run the simulations as time passes and the situation evolves.

While I agree that the idea is good, I imagine that at a point where you are planning to extend your dam by another 20m, you already have to implement the required changes in your foundation and general structure and additionally, turbines and emergency vents have to be upsized for the extended heights. So the only thing you are now missing during build is the extra 20m of dam, as the rest has to be built anyways. This leads back to my initial point of the right amount of over-/underprovisioning..

I am not sure if I understood the second point correctly, but you can obviously tell when a dam becomes too dangerous. This can either be because the foundation has set and you now have increased structural stress, the amount of water has increased beyond the maximum allowed levels or a multitude of other reasons, but they are actively monitored.

> Yeah, exactly. The thing is, where do you draw the line of what is statistically so unlikely that you can deem it improbable?

Important question, because otherwise your costs are absurd and something important (like a power source) never gets built.

Some fields, like road construction, have a cost model built in and at some point are willing to either pull the plug or decide that a few unlikely (originally autocorrected to "unlucky!") fatalities are acceptable.

There are branches of probability theory that deal with these questions rigorously.

https://en.m.wikipedia.org/wiki/Large_deviations_theory https://en.m.wikipedia.org/wiki/Extreme_value_theory

That's what reinsurance actuaries are for. Of course extremely rare events that have not occurred in living memory are harder to model for than life insurance tables.

I am sorry to bring it up, but this is about the same as the way I view the response to COVID by our (Western) leaders.