Blameless portmortems

For organisations committed to continually improving, self-reflection is critical. I particularly liked Etsy's description of how they conduct blameless portmortems when something goes wrong:

A funny thing happens when [staff] make mistakes and feel safe when giving details about it: they are not only willing to be held accountable, they are also enthusiastic in helping the rest of the company avoid the same error in the future. They are, after all, the most expert in their own error. They ought to be heavily involved in coming up with remediation items.

So technically, [staff] are not at all “off the hook” with a blameless PostMortem process. They are very much on the hook for helping Etsy become safer and more resilient, in the end.

The other idea referenced in this article is David Woods' Second Story. The idea is very similar to the concept of double-loop learning, but (I feel) the term is more resonant. Compare First Stories to Second Stories:

First Stories Second Stories
Human error is seen as cause of failure Human error is seen as the effect of systemic vulnerabilities deeper inside the organization
Saying what people should have done is a satisfying way to describe failure Saying what people should have done doesn’t explain why it made sense for them to do what they did
Telling people to be more careful will make the problem go away Only by constantly seeking out its vulnerabilities can organizations enhance safety

I love the statement that "Human error is [a symptom] of systemic vulnerabilities deeper inside the organization". It's so true and yet so rarely embraced by people who instead seek out someone to blame.

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