Executive Focuses on Systemic Change Over Incident Details

Incident Review Shift

During a post-incident call, an SVP of engineering interrupted an explanation of how an issue occurred. The executive stated a disinterest in the specific details of the incident, asserting that such details often lead to empathy and understanding without driving actual change.

Prioritizing Systemic Solutions

Instead of reviewing the incident's specifics, the SVP shifted the conversation to focus on what changes would be implemented to prevent similar occurrences. The executive's perspective was that understanding the 'why' behind reasonable decisions does not inherently lead to fixing underlying problems, and can even reduce the urgency for change.

The Problem with 'Why Did This Happen?'

Many organizations typically ask 'Why did this happen?' after an incident, leading to detailed timelines and explanations. While this provides understanding, it often results in acknowledging the reasonableness of past actions without addressing systemic vulnerabilities. This can lead to repeat incidents because the root causes remain unaddressed.

Focusing on Future Prevention

The SVP's alternative question was: 'What are we changing so that the same class of failure is less likely next time?' This reframes incident response from an investigative exercise into a proactive change management process. The assumption is that reasonable people made reasonable decisions within existing constraints, and the focus should be on altering those constraints.

Driving Organizational Change

This approach aims to drive concrete organizational change by moving beyond blame or justification. By concentrating on actionable changes, organizations can address systemic weaknesses, such as ambiguous ownership, rather than simply understanding the circumstances of a past failure.