dobbse
After this incident we can say, they clearly violated this rule. They cut corners. However, we have no clear view of all the incidents they prevented in the past because they violated that rule. We cannot see that there were twenty other times when violating this rule in exactly this way was exactly what kept things working.
This is the nature of hindsight bias. After the fact, it's completely obvious exactly which of the conflicting rules should have been followed. It is obvious because we now know the outcome.
If you're in the thick of an incident making high-pressure, and high-consequence decisions under duress there is no way to actually predict the outcomes that will become obvious only after-the-fact.
Taking a balanced approach is good universal advice for everything. But in this context, it misses the point of blameless retros.
Our cultural norm is to stop investigations once we find the culprit who cut-corners. The consequences of that systemic habit are that we fail to learn and understand all of the complexity that actually contributed to the failure. We cut short our own learning. What's more, we also effectively teach everyone in the system to conceal or withhold their full understanding in the next incident. So we learn only the most shallow details about what actually happened for this incident, and we suppress what we might learn in the next incident.
http://www.ted.com/talks/jane_mcgonigal_gaming_can_make_a_be...
Persuaded me that the way I learned math is pathologically soul crushing; the way it's taught from kindergarden through university. The first two pages set up a nice metaphor: mathematics is argument and creativity and our traditional math education by memorization and rote repetition are akin to teaching music by reading and writing sheet music without first hearing or playing an instrument.
"No society would ever reduce such a beautiful and meaningful art form to something so mindless and trivial; no culture could be so cruel to its children as to deprive them of such a natural, satisfying means of human expression."
The rest of the article digs into some specific examples.
Mathematics instruction needs an overhaul and back-to-basics isn't The Right Thing.