Blameless Post Mortem Template

Agenda:

§ Dissect the events as we understand (timeline)

§ Discuss actionable steps that can be taken to assert this error
(as we understand it) does not happen again
Outcomes:

§ List of actionable ideas (stories/epics)

§ NOT: “pay attention!” or “be more careful!”
§ Follow-up meeting to observe progress on

Blameless Post Mortem Notes:

Prime Directive
Regardless of what we discover, we understand and truly believe that everyone did the best job
they could, given what they knew at the time, their skills and abilities, the resources available,
and the situation at hand.

“blameless” Post-Mortem
Lack of understanding of how the accident occurred all but guarantees that it will repeat. If not
with the original engineer, another one in the future.

Having a “blameless” Post-Mortem process means that

engineers whose actions have contributed to an accident
can give a detailed account of:
§ what actions they took at what time,
§ what effects they observed,
§ expectations they had,
 § assumptions they had made,
§ and their understanding of timeline of events as they
occurred.
§ and that they can give this detailed account without fear of
punishment or retribution.

Avoid cycle of name/blame/shame:

1. Engineer takes action and contributes to a failure or incident.
2. Engineer is punished, shamed, blamed, or retrained.
3. Reduced trust between engineers on the ground (the “sharp
end”) and management (the “blunt end”) looking for
someone to scapegoat
4. Engineers become silent on details about
actions/situations/observations, resulting in “Cover-Your-
Ass” engineering (from fear of punishment)
5. Management becomes less aware and informed on how work
is being performed day to day, and engineers become less
educated on lurking or latent conditions for failure due to
silence mentioned in #4, above
6. Errors more likely, latent conditions can’t be identified due to
#5, above
7. Repeat from step 1