Blameless Post-Mortems

A post-mortem is an objective investigation of an incident that uncovers systemic weaknesses rather than seeking individuals to blame. It is the most important tool for continuous improvement in IT operations.

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Core concept

After every major incident, a detailed timeline is created and the contributing factors and systemic weaknesses are analysed. The goal is concrete action items that make recurrence technically or procedurally less likely.

Application

• Focus on the How, Not the Who: Avoiding sanctions encourages honesty during fault analysis.
• Public Knowledge: Publishing reports in the internal handbook (Neuland) so all teams can learn.
• Actionable Outcomes: Only post-mortems that lead to measurable changes in the system are valuable.
• Action Item Tracking: Every measure gets an owner and a due date and is tracked through to completion. An action item that no one follows up on fizzles out.

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Related topics

• Culture: Blameless Culture, the related context for Blameless Post-Mortems.
• Technology: Post-Mortem, the learning loop after incidents in Blameless Post-Mortems.
• Methods, the methods section that frames Blameless Post-Mortems.