Incident Reviews Should Change the System, Not Grade the People
Incident reviews often begin with the right intention and drift into the wrong question. Instead of asking how the system allowed a failure to reach customers, teams start evaluating whether individuals followed the expected process. That shift produces cautious meetings, shallow conclusions, and action items focused on reminders or training. It may create the appearance of accountability, but it rarely improves reliability. Look Beyond the Last Human Action An engineer’s mistake may be the final event before an incident, but it is seldom the complete cause. Reliable systems assume that people will mistype commands, misunderstand alerts, overlook documentation, and make decisions with incomplete information. The useful question is not, “Why did someone make that mistake?” It is, “Why was one ordinary mistake able to create this level of impact?” That question directs attention toward weak deployment controls, unclear ownership, unsafe defaults, missing observability, excessiv...