Issues Addressed

Fear of Repercussions Lack of Transparency Missed Learning Opportunities

When to Use

After Critical Incidents To Improve Team Trust For Continuous Improvement

No Blame Post-Mortems

A practice focused on learning from incidents without assigning blame, fostering a culture of openness and continuous improvement.

Origins

Emerged from the DevOps movement emphasizing learning over blame.
Inspired by safety culture practices in aviation and healthcare.
Adopted by tech companies to improve incident response and team dynamics.

Implementation Details

Core Principles

No Blame Post-Mortems focus on understanding the root causes of incidents without assigning blame to individuals. This approach encourages open dialogue and learning, leading to improved processes and systems.

Steps to Conduct

  1. Preparation: Gather all relevant data and context about the incident.
  2. Facilitation: Appoint a neutral facilitator to guide the discussion.
  3. Discussion: Focus on what happened, why it happened, and how to prevent it in the future.
  4. Action Items: Identify actionable steps to address root causes and improve systems.
  5. Follow-Up: Ensure accountability for implementing improvements and share learnings with the broader team.

Best Practices

  • Create a safe environment where team members feel comfortable sharing insights.
  • Document findings and action items clearly.
  • Regularly review and refine the post-mortem process.

Implementation Steps

  1. 1

    Gather incident data and context

  2. 2

    Appoint a neutral facilitator

  3. 3

    Conduct a structured discussion

  4. 4

    Identify and document action items

  5. 5

    Follow up on implementation and share learnings

Usage

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Benefits & Considerations

Benefits
  • fosters a culture of learning
  • improves incident response
  • enhances team trust
Considerations
  • requires a safe environment
  • needs commitment to follow-up
  • may require training for facilitators