Blameless Post-Mortem Culture

The key to learning from your mistakes is to document your failures by performing aroot-cause analysis and writing up a “postmortem”.

A properpostmortem should always contain an explanation of what was learned and what isgoing to change as a result of the learning experience. Then, make sure that the post‐mortem is readily accessible and that the team really follows through on the proposedchanges.

• A brief summary of the event
• A timeline of the event, from discovery through investigation to resolution
• The primary cause of the event
• Impact and damage assessment
• A set of action items (with owners) to fix the problem immediately
• A set of action items to prevent the event from happening again
• Lessons learned