[nyrikki]

Mistakes are the problem, as they will always happen.

The point is to build a culture where you value teamwork and adjust and learn from failures.

This isn't an individual team problem, this is an organization problem.

It is impossible to hire infallible, all knowing employees.

But it is quite possible to enable communication and to learn from pas mistakes.

When you silence employees due to a fear of retribution bad things happen.

People need to feel safe with calling out the systemic problems that led to a failure. If that ends up being the wrong mixture of skills on a team or bad communication within a team that is different.

Everything in this report was a mistake, and not due to gross incompetence from a single person.

The E door bolts as an example was directly attributed to metrics that punished people if they didn't bypass review. The delivery timelines and defect rates were what management placed value on over quality and safety.

Consider the prisoner delema, which is resolved by communication, not choosing a better partner.

[s1artibartfast]

I don't disagree with what you said about this instance, but I'm trying to push back on the knee jerk sentiment that there are no bad employees only bad systems- There are both. cultures that are too permissive of bad actors degrade the system.

Part of maintaining quality culture is maintaining red lines around integrity.

Like I said above, not all errors are recoverable or honest mistakes.

I work in medicine and a classic example would be falsifying data. That should always be a red line, not a learning opportunity. You can add QA and systemic controls, but without out integrity, they are meaningless. I have seen places with a culture of indifference, where QA is checked out and doesn't do their job either.

[filleduchaos]

> I work in medicine and a classic example would be falsifying data

Certainly nobody has ever thought about that before. In fact, there definitely isn't a second sentence in the definition of aviation's just culture that is being completely ignored in favour of weird devil's advocacy.

> 4) Just Culture- errors and unsafe acts will not be punished if the error was unintentional. However, those who act recklessly or take deliberate and unjustifiable risks will still be subject to disciplinary action.

Oh wait.

[s1artibartfast]

I have no problem with the stated safety culture.

I simply agree that "that everyone has the right to work every job" is not a reasonable interpretation of them.

as stated above, a reasonable reader should understand:

> Not everything is a mistake, not every mistake is recoverable, and not all skills are trainable. The fundamental goal is to distinguish between recoverable errors and those that are indicative of poor employee-role fit.

[filleduchaos]

Who is claiming that "everyone has the right to work every job", though? The only person to even bring up the sentence is someone who's handwringing about an interpretation that nobody was making to begin with.

This is why I called it weird devil's advocacy, because what exactly is the point of jumping to caution people about something they aren't doing?

[s1artibartfast]

>Who is claiming that "everyone has the right to work every job", though? The only person to even bring up the sentence is someone who's handwringing about an interpretation that nobody was making to begin with.

Thats the parent in the thread we are posting in in. User Error-Logic replied, and I built upon their reply adding that:

>goal is to distinguish between recoverable errors and those that are indicative of poor employee-role fit.

You and others wanted to dive further.