You can focus on both the “how” and the “who”. I work in an engineering organization where when something sufficiently complicated goes wrong, we do a proper root cause analysis, ask 5 Why’s, propose process improvements, etc.
But sometimes, people just screw up, and preventing every unique screw up, would mean the creation of an absurd amount of process.
For example, one time, excited by the performance results of a colleague, I tried to immediately apply his performance optimization in a different context serving production traffic; we had a team culture of don’t test in prod, etc; but my hubris/excitement meant I powered ahead, which ended up driving up latency, failing requests, and causing a small outage.
The solution in this case isn’t to invent a new process to prevent my mistake, but rather to make sure the engineer knows they screwed up. A bit of shame/guilt leads to self improvement.
If you focus solely on process, and avoid personal responsibility, you may end up missing opportunities for personal growth.
But sometimes, people just screw up, and preventing every unique screw up, would mean the creation of an absurd amount of process.
For example, one time, excited by the performance results of a colleague, I tried to immediately apply his performance optimization in a different context serving production traffic; we had a team culture of don’t test in prod, etc; but my hubris/excitement meant I powered ahead, which ended up driving up latency, failing requests, and causing a small outage.
The solution in this case isn’t to invent a new process to prevent my mistake, but rather to make sure the engineer knows they screwed up. A bit of shame/guilt leads to self improvement.
If you focus solely on process, and avoid personal responsibility, you may end up missing opportunities for personal growth.