The key mental shift (for me anyway) is that if a system can be brought to its knees by a single person, then the system is very likely flawed. You need to design a better system when the flaw in the system is the people. What that often looks like is changing/instituting processes such that quantitative measure (metrics, checklists, etc) governs decisions (thereby removing much, but importantly not all, of the human element), or you design processes in such a way that one person is not in charge of making the decision (the "two person rule", CRs, leadership approval). There are of course other tools but these two are pretty common in my experience.
> if a system can be brought to its knees by a single person, then the system is very likely flawed.
That just means that the person who designed the system deserves the blame.
I'm only half-joking here. You can't just rely on the "system" – someone needs to be responsible, either for the decision or for creating the system that makes the decision.
Having a system/process is not about removing accountability, it's about reducing discretion/cognitive load where it's been identified as risky. In fact, having a system/process in place to point to and say "this individual did not follow the steps/process/rules" makes an unbiased conversation about their performance much more possible.
Yes and this works when you're doing something for the 10th time. It totally doesn't work when you're doing something innovative and risky, which I assume is the kinds of conversations we're talking about here (this subthread is contextual to a senior amazon exec, he's probably not PMing someone forgetting to change the backup tapes)
