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Who do you think should? An engineer who worked on the system? A manager? What law was broken? If you were in their position, how would you know you were breaking the law? Diffuse responsibility is a real problem. 'Teaching to the test' is a real problem. Normalizing risk is a real problem. Blaming individuals is very satisfying, and it's very easy to do with hindsight, but if you want large complex systems to work better, you have to get over individual blame. I'm not saying it's easy, and I'm not saying that we should stop looking for law-breakers, but I am saying that punishment will not lead to better outcomes in the absence of other positive actions. |
"Responsibility is a unique concept... You may share it with others, but your portion is not diminished. You may delegate it, but it is still with you... If responsibility is rightfully yours, no evasion, or ignorance or passing the blame can shift the burden to someone else. Unless you can point your finger at the man who is responsible when something goes wrong, then you have never had anyone really responsible."
Hyman G. Rickover, father of the US nuclear navy