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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.
Core Concept
After every major incident, a detailed timeline is created and the root cause is analysed. The goal is concrete action items that technically or procedurally prevent the fault from recurring.
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.