Who's to Blame?
summary
A single accidental script run halts production for three to four minutes and reframes "human error" as a label not a cause. The talk argues incidents arise from systemic vulnerabilities: cognitive load, organizational pressure, and automation that encodes designer bias. It cites S3, Hawaii missile and Equifax as examples of scapegoating, and recommends blameless postmortems that prioritize concrete remediation steps and a just culture that holds people accountable while surfacing fixes that actually make systems safer.
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