Blameless ≠ consequence-free: making post-mortems stick
Principles
- Blame the system, not the person. Design makes errors likely or unlikely.
- Bias to facts. Timeline first, opinions later.
- Right-sized fixes. Priority is preventing recurrence, not boiling the ocean.
The template
- Timeline. Facts with timestamps and sources (dashboards, logs, comms).
- Customer impact. Who, how long, severity.
- Contributing factors. Technical and organizational.
- Actions. Fix now (days), fix next (weeks), invest (quarter) — with owners and dates.
- Follow-through. Review action status weekly until done.
What changed when we did this
- Repeat issues dropped because actions had owners and deadlines.
- Engineers participated more; psychological safety increased.
- Leaders got better signal on where to invest — people, tooling, or process.
Post-mortems pay off when they drive change. That means owners, dates, and visible follow-up.