The secret to blameless post mortems

How your engineering teams can move past finger-pointing to effectively managing mistakes Sidney Dekker’s theory on ‘bad apples’ holds that complex systems think they would be fine if it were not for the erratic behavior of some unreliable people. According to this theory, when unexpected events are seen in an otherwise safe system, they are typically and conveniently assigned to “human error” and when they are severe to “operator carelessness”.. Similarly, post mortems often look to define and parcel out blame to engineers. Yet it begs the question of how effective the post mortems are if their only purpose is to assign blame. Instead, effective post mortems needs to “acknowledge the human tendency to blame, to allow for a productive form of its expression, and constantly refocus the postmortem’s attention past it.” Post mortems vs retrospectives The problem with post mortems begins with its name “post mortem”, which if you ask […] Read more »