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
- Preparation: Gather all relevant data and context about the incident.
- Facilitation: Appoint a neutral facilitator to guide the discussion.
- Discussion: Focus on what happened, why it happened, and how to prevent it in the future.
- Action Items: Identify actionable steps to address root causes and improve systems.
- 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
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1
Gather incident data and context
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2
Appoint a neutral facilitator
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3
Conduct a structured discussion
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4
Identify and document action items
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5
Follow up on implementation and share learnings
Available Tools
Usage
Usage data is only available to HyperFormation members
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Register NowBenefits & Considerations
Benefits
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fosters a culture of learning
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improves incident response
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enhances team trust
Considerations
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requires a safe environment
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needs commitment to follow-up
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may require training for facilitators