Implement Blameless Postmortems
Blameless postmortems are a collaborative analysis of incidents or failures without assigning blame to individuals. This approach focuses on understanding the root causes, systemic issues, and learning opportunities presented by unexpected events or errors.
Goal
The goal is to create a culture of transparency, trust, and continuous improvement. By focusing on systemic improvements rather than individual blame, teams can identify and address underlying issues to prevent recurrence and enhance resilience and innovation.
Context
Most issues are the result of systemic failures rather than individual mistakes. It is too easy to add another check or approval to prevent a recurrence, but this just adds another blocking dependency and slows down the process. You need to understand the root causes of incidents and failures to properly address them and prevent recurrence. This is where blameless postmortems come in.
Inputs
| Artifact | Description |
|---|---|
| Core Values | The underlying values and beliefs that define the organisation's culture and guide decision-making. |
| Leadership Principles | A set of principles that leaders commit to embodying and promoting within the organisation. |
Outputs
| Artifact | Description | Benefits |
|---|---|---|
| Blameless PostMortem Guide | A template or guide for conducting postmortems, outlining the process, roles, and responsibilities. |
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Anti-patterns
- The Blame Game: Focusing on who was at fault rather than what went wrong and why.
- Skipping Postmortems: Not conducting postmortems, especially for "minor" incidents, missing critical learning opportunities.
- Superficial Analysis: Failing to dig deep enough to find root causes, leading to repetitive issues.
- Lack of Follow-through: Identifying improvements but failing to implement them, resulting in unchanged risk levels.