If you work in IT security or operations, you have probably heard of the blameless postmortem. When it’s done well, in a just culture, individuals and the organization as a whole are held accountable for the circumstances that lead to problems and teams work on designing and implementing reliable improvements.
Unfortunately, worthy ideas are often incompletely understood when they’re implemented in complex situations or ingrained cultures (which can exist in organizations of any age and size). We see this in DevOps, Agile, Scrum, and the blameless postmortem. There’s a new framework. Some people do a great job of implementing it. It grows in popularity. One or more critical aspects of what makes the framework effective are ignored. The framework may develop a bad reputation. Someone comes up with a new perspective that re-centres the essence of the original framework.
In the case of the blameless postmortem, we must recognize that we will assign blame as well as responsibility. I am the rushed guy who pushed an untested change I was confident in through to production. You are the busy person who always skips that pointless extra step in the process. He opened the door for someone who isn’t allowed in the area. She turned the warnings off on the monitoring system because they’re just noise 90% of the time. Point fingers. Acknowledge our flawed humanity. Then be true to the principles of a fair and just culture: move on to building a solution together.
When there is a failure and space for a postmortem, I try to ask why the combination of the human, the system, and the environment worked together to achieve an error. It’s been my experience that failures tend to cluster around the parts of a system that are too simple or too complex for their environment. I’ve found a reliable adjustment often requires understanding and finding flaws in all three aspects.
When the postmortem doesn’t happen, is superficial, or gets delayed, that’s a sign that the systems we rely on to learn and improve our systems are failing. It’s an opportunity for a postmortem on the failure of postmortems. Accept the blame, take responsibility, and make a plan for improvement that everyone affected can and will follow.