Etsy has created a guide for facilitators investigating why accidents happened there: Debriefing Facilitation Guide: Leading Groups at Etsy to Learn From Accidents (PDF)
Notably, they jettison the old model that places blame on people who forgot to do something, and instead focus on learning how they can improve and making changes:
Most traditional accident investigations tend to focus on discovering things around an event that never actually happened. In an attempt to prevent future accidents, there is an underlying assumption (Shorrock, 2014) for this somewhat peculiar emphasis, which is:
Someone did not do something they should have, according to someone else.
Through this lens, what generally surfaces in investigations are “findings” about what people did not do (pay attention, make the right decision, etc.) rather than what they actually did. Without anyone really noticing, these items get labeled as “human error” and through a seductive and convenient contortion of logic, an event that never actually happened is deemed after the fact as the “cause” of the accident. Perhaps unsurprisingly, this results in an obvious recommendation for the future:
“Next time, do what you should.”
Unfortunately, this approach does not result in the safer and improved future we want.
The perspective now known as the “New View” on accidents and mistakes flips this thinking around, providing a different path to improvement and learning (Dekker, 2002). We wholeheartedly believe in this approach at Etsy. We’ve invested in operationalizing it on an organizational level (Allspaw, 2010) and have shared our perspective publicly.