[dasil003]

This is why blameless postmortem culture is so critical, because in any large organization there will be blind spots due the challenges of coordinating hundreds or thousands of individuals, so if you want to even have a chance of making things better, you need to be able to talk concretely about what went wrong without getting personal. Eventually accountability does need to happen, but it needs to be grounded in technical reality and enforced by people who know what they're doing. Many organizations don't have such people (or don't have them anymore), which leads to all kinds of distortions and prioritizing covering your ass instead of making good big-picture decisions.