Systems, Not People

Start with systems, not people Reward early visibility

I loved the talk “Postmortems Without Blame: Running Real, Transformative Incident Reviews” by Agata Skorupka at DevOpsDays London.

It linked beautifully with so much of the literature that shapes how we think about work.

Amy Edmondson’s research on psychological safety (“Right Kind of Wrong”) reminds us that people won’t surface problems early if the culture punishes vulnerability.

L. David Marquet’s “Turn the Ship Around!” shows how intent-based leadership creates conditions where responsibility is distributed, not concentrated, which makes early signals stronger.

Dan Pink’s work on motivation (“Drive”: autonomy, mastery, purpose) explains why engineers need more than blame or reward. They need meaning.

The emphasis on starting with systems rather than people echoes Deming’s famous line: “A bad system will beat a good person every time.”

It also recalls Sidney Dekker’s “Just Culture”, which highlights how focusing on human error blinds us to the deeper systemic issues that make failure inevitable.

And when we talk about rewarding early visibility, it’s hard not to connect to Gene Kim, Jez Humble, Nicole Forsgren, and their research in Accelerate, where high-performing organisations thrive by shortening feedback loops and making work observable as soon as possible.

All of this makes me think: if we want truly transformative incident reviews, we need to design them as spaces where systems are interrogated, signals are surfaced early, and people are safe to tell the truth.

Originally posted on LinkedIn.