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Whose Fault Was It?

By | November 25, 2014 in ITIL

Incident Management: Who's Fault Is It?

We all know that IT service management is about people, processes and tools, but for some reason we always seem to focus on the processes and the tools and forget about the people.

I once worked with an organization where the first question that was asked after a major incident was always “Whose fault was it?”, or something very similar. The senior IT manager needed to have someone to blame for everything that went wrong. As a direct result of this management style the organization never managed to improve. It was almost impossible to find out the truth about what sequence of events had led to a major incident because everyone was hiding vital information in an effort to avoid being the person that got the blame.

Contrast that with the ideal of a “blameless post mortem”. This is the idea that you should make it easy to share and learn from mistakes. If somebody in the organization makes a mistake and has the confidence to tell their colleagues immediately, then everyone can work on rectifying the situation, and thinking about how to avoid it happening again. Because the mistake is identified early it can usually be fixed sooner, reducing both the impact and cost of the mistake, and because everyone knows what happened there is a good chance that a repeat of the mistake can be avoided in the future.

This idea of sharing our mistakes and learning from them is not just useful for incident management. The same applies to everything we do in service management. For example:

  • A no-blame culture can improve change management, by helping us to see why some changes go wrong, and how we could prevent similar events in the future.
  • Configuration management is critically dependent on identifying and correcting errors in the data, and understanding how they happened so we can prevent them happening again.
  • Project and portfolio management must be able to identify failing (and failed) investments and stop pouring more money into things that will never work. Blameless reviews can help to make this happen.

I hear people saying that they can’t implement this kind of approach because if there are no consequences for doing things wrong then people won’t learn from their mistakes. This shows a complete lack of understanding of human psychology. It is well established that the best way to help people learn is to catch them when they are doing something right and offer positive feedback to encourage the desired behaviour. Punishing mistakes is a very ineffective way of correcting people’s behaviour.

Changing the culture of an organization can be very hard. If your organization’s instinctive reaction to a problem is seeking to assign blame then how can you change? The first thing to understand is that you can’t turn this around quickly, it will take time. But it really is worthwhile. Many years ago I was a senior technical consultant, providing 2nd and 3rd line support on hardware and software products, and diagnosing complex system problems. Management was not excessively severe in assigning blame, but very few technical people in the organization were willing to admit to making mistakes. I was sufficiently senior that I didn’t need to worry about how other people saw me, so I made a conscious decision to start talking openly about all the mistakes I made. Some of these were quite small but others were a big deal; I recognized that if I was making this many mistakes then other people almost certainly were too, and I believed that by being open about my own mistakes I could encourage others to be more open about theirs. After a while I noticed the culture had gradually changed, and it was now normal for people to talk about their mistakes.

Even if you currently have a blame free culture there are probably people in your organization who are nervous of owning up to things they do wrong. Anything you can do to help them talk openly about their mistakes will help your organization to learn. The sooner we discover a problem the cheaper it is to fix.

If you want to change your culture to one that is open about mistakes and learns from them then what can you do? It’s hard to change an organisation’s culture, but you can sometimes change behaviour to encourage the change that you hope to see. Here are a few things that I’ve seen work for other organizations:

  • Get buy-in from senior management. Make sure they understand the potential benefits of openness, and the huge cost of hidden mistakes
  • Communicate, again and again. Make sure that everyone in the organization understands the change you want, and why you want it.
  • Make absolutely sure that all of your managers understand what you are doing, and why, and support it with their behaviour.
  • Start talking about your own mistakes, and encourage other managers to do the same. It can be hard at first but it gets easier with time.
  • Publicise success stories where mistakes were identified early; show how this delivered real value to the organization and enabled you to learn and improve.
  • Reward the behaviour you want to encourage. When someone shares a mistake, make sure that you celebrate the opportunity to learn, rather than assign blame.

How well does your organization balance its investment in people, process and tools? Could you benefit from encouraging people to talk about mistakes?

Like this article? You may also like: Knowledge Management Is Not Just About Document Repositories.

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Stuart Rance

About Stuart Rance

Stuart is an ITSM and security consultant, working with clients all round the world. He is one of the authors of ITIL 4, as well as an author of ITIL Practitioner, ITIL Service Transition, and Resilia: Cyber Resilience Best Practice. He is also a trainer, teaching standard and custom courses in ITSM and information security management, and an examiner helping to create ITIL and other exams. Now that his children have all left home, he has plenty of time on his hands for contributing to our blog - lucky us!

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