The public report is nice and we can see a sequence of mishaps from it, that shouldn't have been allowed to happen but which (unfortunately) are not that uncommon. I've done my share of mistakes, I know what's like to be in emergency mode and too tired to think straight, so I'm going to refrain from criticizing individual actions.
What I'm going to criticize is the excess of transparency:
You absolutely DO NOT publish postmortems referencing actions by NAMED individuals, EVER.
From reading the whole report it's clear that the group is at fault, not a single individual. But most people won't read the whole thing, even less people will try to understand the whole picture. That's why failures are always attributed publicly to the whole team, and actions by individuals are handled internally only.
And they're making it even worse by livestreaming the thing! It's like having your boss looking over your shoulder but a million times worse...
What I'm going to criticize is the excess of transparency:
You absolutely DO NOT publish postmortems referencing actions by NAMED individuals, EVER.
From reading the whole report it's clear that the group is at fault, not a single individual. But most people won't read the whole thing, even less people will try to understand the whole picture. That's why failures are always attributed publicly to the whole team, and actions by individuals are handled internally only.
And they're making it even worse by livestreaming the thing! It's like having your boss looking over your shoulder but a million times worse...