
Blameless post-mortems and a just culture (2012) - chipperyman573
https://codeascraft.com/2012/05/22/blameless-postmortems/
======
leggomylibro
I once worked somewhere that did blameless technical postmortems very well.
Whenever something broke, we kept asking questions until we had uncovered what
went wrong, and we constantly reminded each other that our failings were in
the process, not the people.

It worked great, and we ended up with much more robust systems than most other
places I'd worked.

Sadly, they didn't apply the same ideals to social faux pas. We had an older
gentleman working for us who, on hearing a younger member of the team propose
an idea, said: "okay, I'll play the straight man: why won't this cause [...]"

In the poor guy's generation, "straight man" was a stand-up comedy term for
the person who acts deadpan and surprised while their partner makes with the
comedy. But after explaining his actions and the expectations/assumptions
behind them, he was reprimanded, ostracized in the office, and left before
long.

Even though I liked working on the technical systems at that job, I felt
isolated and uncomfortable speaking with my peers after that. I've never been
good with people, and what if I made a mistake?

That sort of terror is what non-technical folks feel when you ask them to
start taking on new responsibilities, and it's why these blameless systems are
so important.

~~~
Ididntdothis
I often hear about this stuff but I have never seen it myself. Do people
really ostracize others for saying a sentence they don’t like? I can see it if
somebody constantly says stupid or offensive things but not for a few mistakes
(are they even mistakes?).

~~~
SpicyLemonZest
I can't vouch for ostracism specifically, but we just had someone at our
company add a Slack bot to correct anyone who says the word "guys", and let me
tell you I did not feel like it would be appropriate to complain.

~~~
frank086
With everyone remote HR has sadly discovered a sudden love of policing slack.

I saw another engineer get hit for talking about triggering a job since "using
triggering improperly downplays the trauma of survivors".

Not sure what that means other than it is time to set the LinkedIn status to
looking.

~~~
Ididntdothis
"I saw another engineer get hit for talking about triggering a job since
"using triggering improperly downplays the trauma of survivors". "

This is nuts. Where is this? Silicon Valley?

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kqr
Only tangentially related but I have to get it out of my system anyway:

I watched the latest season of the F1 documentary on Netflix, and what stood
out beyond anything else to me was that every team pitted their own drivers
against each other, had a "you win or you lose" mentality, screamed at people
for messing up, and so on.

All teams except one. One team iterated how they "win as a team and make
mistakes as a team", mistakes are an opportunity to learn, and so on. One team
showed pretty clearly how they had a good culture surrounding failures.

I'm not at all surprised that this one team is the team that has consistently
won the last 6 years in a row.

Why aren't more teams copying this? Why is this one team not more secretive
about their recipe to success?

~~~
aahortwwy
> Why is this one team not more secretive about their recipe to success?

It's not a secret. Many other organizations (not in F1, by your description)
operate this way. It's well understood, but...

> Why aren't more teams copying this?

... everyone on the team needs to buy in to this approach. One selfish team
member can slowly ruin the whole thing.

The uncomfortable reality of these cultures is that when someone in the
culture is not truly committed, or is putting their self-interest ahead of the
team, they need to be removed. A lot of leaders are not strong enough to
recognize that and take action.

~~~
bob33212
It is similar to why organizations don't hire 10x engineers only. It is
difficult, a lot of work and hiring just one bad manager could cause the 10x
engineers to leave or become unproductive. It is far easier to treat engineers
like cogs and hire people that check the right boxes and throw them into a
standard scrum process.

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quartz
I'm a cofounder at Kintaba ([https://kintaba.com](https://kintaba.com)) where
we spend a lot of time with companies that are implementing postmortems as
part of their larger incident management process and it has been fascinating
to see how varied the adoption of the practice is even in SV despite the value
being well accepted for over a decade in tech (longer in other research
circles).

I often recommend anyone who is interested in the topic to check out Sidney
Dekker's Field Guide to Understanding Human Error [1].

It's a very approachable read and goes into great detail about the underlying
theories of safety research that support the value of blame-free cultures and
postmortems and addresses common counter-arguments, particularly around the
idea that lack of blame = lack of accountability.

Also worth checking out the (free) google SRE Book chapters on Incident
Management [2] and Postmortem Culture [3].

[1] [https://www.amazon.com/Field-Guide-Understanding-Human-
Error...](https://www.amazon.com/Field-Guide-Understanding-Human-
Error/dp/1472439058/)

[2] [https://landing.google.com/sre/sre-book/chapters/managing-
in...](https://landing.google.com/sre/sre-book/chapters/managing-incidents/)

[3] [https://landing.google.com/sre/sre-
book/chapters/postmortem-...](https://landing.google.com/sre/sre-
book/chapters/postmortem-culture/)

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xrd
I love blameless postmortems. And, it isn't really whether the team or the
team lead decides to do a blameless postmortem. It's whether the company
values looking at things this way. And, those values change over time, and
shift when the times are good or bad (financially).

I would really love to read about a blameless postmortem that happened in a
dying company where everyone was backstabbing each other. Now, that would be a
good story!

In fairness, this story does convey that. The "second story" part is great.

I do wish there was a little more about how management came around to seeing
it, how they rectified bonuses and pay and PIPs. There is an untold journey
here.

~~~
kqr
I have been recommended the book "Turning the Ship Around" for an account of
how to grow a new good culture in a decisively bad one. It's probably not an
exact recipe for being able to hold blameless postmortems, but I suspect it
could contain some valuable information.

If anyone knows how well it applies to this situation, please do tell me!

~~~
asplake
TBH I’m not sure of its relevance to postmortems specifically but I’d highly
recommend the book. Turn the Ship Around, Marquet. Great audiobook too.

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Mikhail_Edoshin
There's a Youtube talk [Martial Arts Mind][1] by Peter Ralston about a change
he underwent when he stopped seeing the opponent as an adversary. It's a very
deep subject. Easy to get wrong too :)

[1]:
[https://www.youtube.com/watch?v=wi7ph8GrRDk](https://www.youtube.com/watch?v=wi7ph8GrRDk)

------
codesections
> We must strive to understand that accidents don’t happen because people
> gamble and lose.

The problem is that _some_ accidents do happen because people gamble and lose
– or rather, because people cut corners is ways that _probably_ won't matter
but sometimes really, really do.

The best approach needs to balance both causes of error. I agree that most
organizations tend to err too far in the "blame someone" direction – but that
doesn't mean that it's impossible to err by going too far in the other
direction.

~~~
hoorayimhelping
As I understand it the key to the blameless and just culture is to keep going
to the bottom of it: "You cut corners. You were incentivized to cut corners.
Why? Why do those incentives exist? What can we do to remove those incentives
in the future?"

The core of the philosophy is assuming people come to work to do a good job,
and when they don't do a good job, there are reasonable explanations that
involve people making locally rational decisions. The goal is to make the
system stable in a way that making locally rational decisions translates to
globally good decisions.

~~~
peteradio
And what happens when the finger starts pointing back towards business
imposing terrible incentives?

~~~
jonfw
If you find a business incentive as a root cause, you blamelessly discuss ways
you can change that incentive.

~~~
jiveturkey
LOL!

has this ever, ever happened?

~~~
jonfw
Absolutely- happens all the time in organizations with good management :)

~~~
peteradio
Hmm, something very circular seem to be happening in your argument, can't
quite put my finger on it.

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notyourday
Blameless postmortems should come with the equal pay ( as in equal dollar
amount, equal value of equity, and equal value of other perks) for everyone in
the tech organization.

If it does not, then it is a propaganda tool embraced by people who extract
more value from the people below them.

~~~
diegoperini
I don't understand the argument. (I didn't vote on your comment)

~~~
notyourday
If it accepted that is not a person or persons whose mistakes create problems
requiring postmortems meaning it was the collective that made mistakes then it
should also be accepted that it is never a person or persons whose
accomplishments propelled the company forward rather it is the collective. So
everyone in the collective should get paid the amount of money for equal
contributions to ups and downs, should not they?

~~~
diegoperini
On a scale from "individual" to "collective", both blame and success can be
attributed to either extreme (or middle) on a case by case basis. I don't
believe it can be possible to claim a universal generalization for all cases.

~~~
notyourday
Is there a single case where a company which practices blameless downside
practices a collective upside?

~~~
diegoperini
It is rare (so sad) but yes, there is. I work in such a company and I am not
the employer.

~~~
notyourday
I would happily accept the blameless postmortems in such a company.

~~~
diegoperini
Yes. But it's a dynamic relationship and radical equity is still not justified
even here. Equity and worth is not a function of solely participation. It's a
mixture of participation, loyalty, honesty, competence, sacrifice, seniority
and priorities in life. You can always name more variables and it will always
put the radical argument in a greyer zone.

Edit: I use the word "radical" as in outstanding, outside of the box,
noticeably different. It isn't meant as a derogatory term.

~~~
notyourday
> But it's a dynamic relationship and radical equity is still not justified
> even here. Equity and worth is not a function of solely participation.

It is a function solely of contribution in whatever way one contributes be
that by being the smartest person in a room who needs only one minute to do
what it takes others three months, or by being people who labor for three
months so the smartest person in a room can do something else.

Since the negative contribution is evenly split among everyone ( blameless )
so should be the positive contribution.

~~~
diegoperini
What you define is not contribution, it's participation. Killing meritocracy
entirely also kills the incentive to improve oneself. Distributing equity non-
equally is just one of those dials which if you adjust slightly, you reward
people who are able to self improve more. Do it too much, you alienate your
team (as you pointed out). Do it never, you reward the lazy by not rewarding
the hardworking. I think you are on the right track with your intentions but
having a balanced approach is the key and choosing one extreme over the other
is not the path forward here.

This has been a fun debate but I believe what I think about the topic can be
summarized as this:

Healthy competition without the toxicity is possible in the workplace. It is
just hard and needs careful attention to detail. If you ask how much, that's
probably the subject of ideology. When ideologies battle, it's either bloody
and both sides lose or it's small wins and loses achieved by mutual
compromise. No matter where the balance is met, it must progress with
dialogue.

