Blameless postmortem.
also: blameless postmortems · postmortem · postmortems · post-mortem · five whysA written review after an incident that asks why the system allowed the failure, not who erred, and ends in concrete action items.
the two-minute refresher
- Goal: learn and improve, not punish.
- People acted in good faith with what they knew; systems that allow human error are the cause.
- Five whys: keep asking why until you reach a systemic cause.
- Every postmortem ends with owned, dated action items.