Blameless Postmortems: Shipping that Learns

• Blameless postmortems shift focus from who failed to what the system allowed.
• Roots in aviation and safety science (Reason, Dekker); tech popularized via Google SRE.
• Value: faster recovery, better design, higher trust; risks: performative rituals without follow‑through.
• Add action tracking, owner, due dates, and review loops.

“No Blame, More Learning”: The Postmortem as a Cultural Operating System

When systems fail, we can hunt culprits—or investigate conditions. Blameless postmortems choose the latter. They’re not softness; they’re efficiency. People share more when they’re safe; you learn faster when narratives aren’t edited by fear (see Postmortem documentation, Just culture). 🧯📝

Origins & Timeline

• 1930s–60s: Aviation checklists and accident boards develop systemic analyses.
• 1990s: Human factors (James Reason’s Swiss Cheese Model) and high‑reliability organizations influence healthcare/nuclear.
• 2000s–2010s: SRE codifies blameless retros; tech firms publish public writeups.
• Today: Cross‑industry adoption; regulators encourage learning reviews.

Anatomy of a Good Postmortem

• Title & severity; timeline with evidence (logs, graphs).
• Customer impact (duration, scope); detection & response.
• Five whys → conditions (not people); contributing factors (org/process/tech).
• Actions with owners, dates, and risk ranking.
• Communication plan (internal + external).

Template Box

Quote: “Humans are the adaptability in the system, not the bugs.” — Safety II viewpoint

Metrics & Anti‑Patterns

Metrics: MTTR, time‑to‑detection, repeat incident rate, action completion.
Smells: Name‑and‑shame language, vague actions (“be more careful”), loss of psychological safety, and never‑finished follow‑ups.

Accessibility: Publish in plain language; add diagrams; include alt text for charts.

Ethics & Privacy

Balance transparency with PII protection and partner sensitivities. Use redaction judiciously; default to learning over PR spin.

FAQ
Q: Isn’t “blameless” naive?
A: Accountability remains—in actions and design—not in shaming individuals.