alt Hacker NewsIt reminds me of NTSB reports, particularly around aircraft accidents, where even if one person was definitely to blame for the accident happening (eg a pilot performed an incorrect action that least to the loss of a plane), the report will recommend things like better training and testing standards to make sure that a pilot who crashes through incompetence can be trained more, without blaming the pilot specifically
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That is the mindset, but you really see a general lack of this in the industry... even as the term has been so popularized.
At the end of the day if your intern can take down your production DB, about 5 other things went wrong first to put them in a position to be able to do so.
Systems are complex, and sometimes the holes in the Swiss cheese line up.
Swiss Cheese model, to prevents bad things from happening we need to focus on preventing situations where those bad things could even arise.
Britain's Maritime Accident Investigation Branch (EU rules required members to have such agencies, although I think the UK had several of them before that anyway) published a memorable report where, despite this usual practice they offer zero recommendations.
The accident was basically some guys took a fishing boat out, did a lot of heroin, got into trouble and all died. And there were no recommendations because heroin is already illegal, operating a fishing boat while on heroin is also illegal, so, yeah, we already told you this was a terrible idea, there's nothing to recommend.