Business Faith

Blameless Reviews & High Trust Culture

This article borrows heavily from the seminal article by John Allspaw, then CEO at Etsy. Though based on a technology company’s successful approach to handling failures and accidents, it can be easily applied to ministry. I basically replaced engineers with volunteers and like paint on primer, it became an article about handling issues in ministry.

Discussing how they at Etsy handle errors and mistakes, I began to think about how growing Churches can learn from this. Anyone building a ministry at any size will deal with failed events, programs, and projects. Failure doesn’t care about planning, prayer, budgeting, follow-up or marketing. It happens. It’s part and parcel of running a multi-department, multi-initiatives ministry. How though, do you deal with failures that involve people? Maybe due to lack of action, slow response, little attention to detail? What do you do with the ineffective? Make an example of them, relieve them of their duties and responsibilities or train them? Ideally in the business world, such people are fired, in ministry, they are lovingly re-routed to less impacting work.

Another way would be to view the slip-ups and lapses in judgement as a learning moment. Having Blameless Reviews on issues and failed initiatives should be a part of that.


What does Blameless Review mean? Does it mean everyone gets “off the hook” for making mistakes? Not really. Let’s look at the term “gets off the hook”. Having a High Trust Culture in ministry means that there’s a deliberate effort to empower volunteers and hold them accountable. It means looking at mistakes and issues in a way that focuses on situations, processes, decision-making, and the ability to change factors that decide the outcome given to volunteers of a ministry.


Having a Blameless Review means that volunteers who contributed to the failure or issue can give a detailed account of

  • What actions they took, and when
  • What effects they observed
  • What expectations they had
  • What assumptions they made
  • Their understanding of timelines of events as they occurred

They give this account without fear of punishment or retribution. Why wouldn’t they be reprimanded? Well, because a volunteer who thinks they’re going to be reprimanded or punished have no incentive to give the necessary details needed to get an understanding of what caused the failure/issue. Not understanding what caused the issue or failure means it will almost definitely happen again. If not by the same volunteer, another one in the future. This fundamental shift on issues and failures improves the quality of ministry initiatives. The blame game causes information (good or bad) to no longer flow freely. We’re inadvertently encouraging more mistakes and failures because we’re not learning from them. Instead of seeing people as the root cause of failures and issues, we should look at situations as the main factor. Fear of punishment also leads to cautious defensive behaviours and not necessarily careful, attention to detail.


The cycle of name/blame/shame can be looked at like this:

  1. Volunteer takes action and contributes to a failure or issue.
  2. Volunteer is punished, shamed, blamed, or retrained.
  3. Reduced trust between volunteers on the ground (the “sharp end”) and leadership (the “blunt end”) looking for someone to scapegoat.
  4. Volunteers become silent on details about actions/situations/observations, resulting in “Cover-Yourself” volunteering (from fear of punishment).
  5. Management becomes less aware and informed on how tasks are being performed, volunteers become less educated on lurking or latent conditions for failure due to silence mentioned in #4, above
  6. Errors/Issues more likely, latent conditions can’t be identified due to #5, above
  7. Repeat step 1

We need to avoid this cycle. We want the volunteer who has made an error give details about why (either explicitly or implicitly) he or she did (or didn’t do) what they did (or didn’t do); why the action (or inaction) made sense to them at the time. This is paramount to understanding the pathology of the failure/issue. The action (inaction) made sense to the person at the time they took it, because if it hadn’t made sense to them at the time, they wouldn’t have take the action in the first place.


The base fundamental here is something Erik Hollnagel has said:

We must strive to understand that accidents don’t happen because people gamble and lose.

Accidents happen because the person believes that:

…what is about to happen is not possible,

…or what is about to happen has no connection to what they are doing,

…or that the possibility of getting the intended outcome is well worth whatever risk there is.

Another Perspective

Getting the perspective of the volunteer provides another view point to an issue or failure. In Review meetings, we want to find that other perspective to help understand what went wrong. From Behind Human Error below is the difference between the initial perspective (first story) and other perspective (second story):


First Stories Second Stories
Human error is seen as cause of failure Human error is seen as the effect of systemic vulnerabilities deeper inside the organization
Saying what people should have done is a satisfying way to describe failure Saying what people should have done doesn’t explain why it made sense for them to do what they did
Telling people to be more careful will make the problem go away Only by constantly seeking out its vulnerabilities can organizations enhance safety


Allowing Volunteers to Own Their Own Stories

When volunteers feel safe to make mistakes and give details about it, they are willing to be held accountable, and are enthusiastic in helping the rest of the ministry avoid the same error/issue in the future. They are, after all, the most expert in their own error. They ought to be heavily involved in coming up with remediation items.

So in essence, volunteers are not “off the hook” with a Blameless Review process. They are on the hook for helping the ministry operate with less failures or issues, and become more responsive in the future. Volunteers will mostly find it worthwhile to make things better for others.

So how does a ministry enable a High Trust Culture?

  • Encourage learning by having these Blameless Reviews on issues and failures
  • The goal is to understand how an issue/failure could have happened, in order to better equip ourselves from it happening in the future
  • We seek out the Other Perspective, gather details from multiple perspectives in failures, and we don’t punish people for making mistakes.
  • Instead of punishing volunteers, we instead give them the requisite authority to improve the outcome by allowing them to give detailed accounts of their contributions to failures/issues.
  • We enable and encourage volunteers who do make mistakes to be the experts on educating the rest of the ministry how not to make them in the future
  • We accept that there is always a discretionary space where humans can decide to make actions or not, and that the judgement of those decisions lie in hindsight.
  • We accept that the Hindsight Bias will continue to cloud our assessment of past events, and work hard to eliminate it.
  • We accept that the Fundamental Attribution Error is also difficult to escape, so we focus on the environment and circumstances people are working in when investigating issues.
  • We strive to make sure that the blunt end of the ministry understands how tasks are actually getting done (as opposed to how they imagine it’s getting done) on the sharp end.
  • The sharp end is relied upon to inform the ministry where the line is between appropriate and inappropriate behavior. This isn’t something that the blunt end can come up with on its own.

Failure/issues happens. In order to understand how failures/issues happen, we first have to understand our reactions to failure. One option is to assume the single cause is not being committed, paying enough attention to detail, or giving the best effort and reprimanding volunteers to make them “be more committed” or “give God their best!”

Another option is to take a hard look at how issues actually happen, treat the volunteers involved with respect, and learn from the event.

That’s why we have Blameless Reviews in ministry, and how we create a High Trust Culture.



Original Article:

Erik Hollnagel:

Behind Human Error:

Hindsight Bias:

Fundamental Attribution Error:





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