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How to Facilitate a Blameless Postmortem

Learn from incidents and improve future reactions – without the blame game

By Gustavo Razzetti

November 3, 2022

If you don’t want your team to repeat mistakes, replace blame with  intentional feedback

Blame is a sign of an unhealthy culture. Teams often jump into the name, blame, and shame game when something goes wrong, trying to find who to punish. However, this punitive approach to mistakes doesn't address the real issue but actually perpetuates the flaw. That's why facilitation a blameless postmortem is vital.

The underlying belief of a blameless culture is that mistakes are generally a product of faulty organizational cultures rather than the fault of one or more individuals. Addressing systemic issues requires tackling the root of the problem rather than finding the culprit.

A blameless culture doesn't mean a lack of accountability. On the contrary, when teams own their mistakes, they learn from them, increasing ownership and responsibility.

A just culture understands that people function within a system designed by an organization. Usually, organizations seek to identify those responsible and punish them. If you want to prevent errors, start by improving the system.

In this post, I will explain how to replace blame with curiosity, introduce the Blameless Postmortem Canvas, and discuss how to facilitate productive conversations – without the blame.

Blameless Postmortem: Mindset Shift

What is a post-mortem?

A post-mortem is a written record of an incident or event that describes:

  • The incident from end to end
  • The event impact
  • The incident's root cause
  • The actions taken to mitigate or resolve the issues (immediately and after the fact)
  • Lessons and follow-up actions to prevent the incident from happening again

The Blameless Postmortem is an exercise practiced by crafts and vintage items e-commerce website Etsy among other tech companies. It's like a postmortem but without the blame. I use this tool to debrief projects that went wrong or which can be improved with clients in various industries, not just tech incidents.  

Etsy's CEO Chad Dickerson wanted to shift the conversation from "Who's the CEO going to fire?" to learning from mistakes. This practice has helped Etsy employees take more risks and move faster.

A just culture is a concept related to systems thinking that emphasizes that mistakes are generally a product of a faulty system rather than solely a human error. It encourages people to focus on learning rather than on blame. In a just culture, people ask, "What went wrong?" versus "Who caused the problem?"

When leaders 'normalize' mistakes, people address them in the open instead of hiding them. Inspired by this principle, Dickerson adopted the blameless post-mortem at Etsy. As the CEO told Business Insider: "One of the things I allowed people to do is make mistakes more freely. The best way to learn to ride a bike is to ride the bike and fall down."

Holding a blameless postmortem requires shifting the conversation from pointing fingers to finding out what happened and how teams can improve. Google,  Hootsuite, and Atlassian are also advocates of this method.

We're hardwired to use blame to release negative feelings, especially guilt. Professor and author Brené Brown describes the human tendency to blame others as "a way to discharge pain and discomfort." We often try to fault others for our mistakes because it makes us feel like we're in control. However, leaning into the discomfort of mistakes is how we can learn from them. "I'd rather it be my fault than no one's fault," the shame and vulnerability expert suggests.

Owning our mistakes is easier said than done. Practicing it as a team makes the process easier – team members learn to own their mistakes as one.

Detractors assume that blameless postmortems make those who made a mistake feel better – a goal that would probably stifle accountability. However, this exercise aims to promote psychological safety by removing the fear of looking stupid or losing one's job. By encouraging courageous conversations, you can prevent your team from making the same mistake again

Before kicking off the activity, it's vital to adopt the right mindset. Here are some guidelines to facilitate an effective postmortem without the blame.  

Assume good intentions: People usually act based on the information they had at the time. Assume everyone involved acted with the best intentions.

Don't react emotionally: Take a deep breath before you react, then ask the right questions and explore what caused the error.

Focus on facts, not perceptions: Encourage the team to reflect on what actually happened and what they would do differently next time.

Identify causes, not culprits: Move from "who?" to "why?" Understanding the root cause might require more effort, but it will help prevent future mistakes.

Be consistent: This advice comes from Atlassian's playbook: "If one post-mortem is blameless and others aren't, the removal of fear and introduction of more openness won't work."

Blameless Postmortem: Step-by-Step Facilitation Guide

Who completes the blameless postmortem?

The team responsible for a failed project or service is accountable for running the blameless postmortem exercise. Ideally, you need an external facilitator to guide the conversation and ensure blame doesn't get in the way of learning. Focus on what, how, and why questions rather than who.

The Blameless Postmortem Canvas is a visual tool that will help you capture all necessary information and facilitate a structured conversation.

Download the template in PDF, MURAL, or Miro format.

The process and framework I use with my clients to facilitate a blameless post-mortem has three key steps:

1. RECAP the event: The goal is to capture all the facts to really understand what happened, from the initial ask to the end results/outcome.

2. REFLECT on the behaviors/ reactions: Understand the key factors that caused the mistake or error – and what systemic issues you need to improve.

3. IMPROVE based on learnings: Identify solutions and define an action plan.

Let's discuss the three steps – one at a time.

1. RECAP the event

This is the most critical step, setting the tone for the entire conversation.

The RECAP aims to understand the event in a very descriptive and objective fashion – focus on facts, not perceptions or emotions.

The people directly involved should provide a timeline of the project or incident, starting with the request and finishing with the outcome/ end result. Capture all the details on the Blameless Postmortem Canvas.

What was the original ask?

Many projects are set up for failure. Understanding the original request, how the project was initiated, by whom, and the pre-defined outcomes (deadlines, deliverables, expectations, etc.) will help determine how the project got started – and if it was set up for success or failure.

What happened from beginning to end?

Describe the key events, practices, and incidents. Encourage people to be honest and detail things as they happened, accepting that mistakes will always occur. A blameless postmortem will ensure your team doesn't repeat the same error.

What was the outcome?

Describe what went wrong or didn't work as expected. Describe what internal and external customers experienced. Use images or graphs to help people remember the end results.

What Are We Missing?

Once the key members finish describing the facts, have everyone review the notes and ask questions to see if something is missing. The goal is to ensure all facts are covered before moving into the next step.

2. REFLECT on how the team behaved/ responded

Potential Causes of Failure

What caused the negative outcome?

Adopt the mindset of a detective, observe the facts without judgment, connect the dots, and seek the "Aha!" moment. Be relentless!

Make sure everyone focuses on understanding what went wrong instead of finding the culprit.

Focus on facts and behaviors – always assume positive intent. The facilitator should encourage the team to use "I" statements rather than "you" statements to avoid the temptation to blame others. For example, instead of saying, "your team failed to turn things in on time," say, "I had to rush the review process because I received the information later than originally planned."

How did we respond when things started to go wrong?

There are two elements that your team needs to uncover during a blameless postmortem: what caused the original incident and if the initial reaction helped mitigate the issue or made things worse. Most of the time, by trying to put out a fire, we create a bigger one.

How did we find out about the incident? Who responded, when, and how? Were there any delays or barriers that limited the team's response?

Continue capturing all the notes on the Blameless Postmortem Canvas.

Move beyond the incident and focus on finding the root cause. Usually, when something goes wrong it's because there's something in the system that needs to be repaired. Focus on communication, process, expectations, and other elements that might lead to similar incidents. If you compare this incident to previous ones, are there any similarities? By focusing on the pattern, your team can uncover systemic issues.

Don't confuse proximate causes with root causes.

The Atlassian blog makes a clear distinction between the two:

Proximate causes are reasons that directly lead to an incident.

Root causes are reasons at the optimal place in the chain of events where making a change would prevent the entire class of incidents.

A blameless postmortem seeks to discover root causes and decide how to best mitigate them.

Go deep, following the train of thought to its logical conclusion by using the five whys technique – ask "Why?" five times to get to the root of what happened.

Here's an example from Toyota:

Most Important Cause to Address

What could we have done differently?

The goal here is not to criticize and second-guess someone else's decision after the event is finished. Being a Monday quarterback is always easy. The facilitator should remind the team of the blameless mindset if someone feels like they are receiving blame. Participants should focus on improving the process, not showing how smart they are.

What have we learned?

Discuss what went well, what could have gone better, and where the team got lucky. Identify improvement opportunities.

Capture the key lessons the team uncovered by reflecting on what went wrong - or not as good as it could have been. Once again, focus on behaviors and processes. Promote psychological safety to ensure people feel safe to speak up, be candid, and own their mistakes.

3. IMPROVE based on learning

Brainstorm Solutions

What can we do to prevent a similar incident?

Discuss with your team what they will do to prevent similar incidents from happening again.

Consider different perspectives. Team members with different skills, backgrounds, and experiences can see things that leaders are missing. Studies show that teams with the right combination of cognitive diversity and psychological safety are better at learning, collaborating, and improving.

What does a "better response" look like?

Consider how the system, not the person, should have responded better. If the team faces a similar incident, can they have a better response? Even if someone did something that directly led to an incident, instead of asking, "Why did (name) do this?" ask, "Why did the system allow/ encourage them to do this?"

Action Plan

Which solutions do we want to implement?

Select individual and collective action items. Prioritize the solutions your team wants to implement. Identify both quick wins and structural wins. Quick wins can build momentum and remove unnecessary pain, while structural wins require more time and resources but will prevent costly and significant incidents from happening.

What? Who? When?

Define concrete next steps, who will lead the implementation, and clear deadlines.

blameless postmortem shift culture from blame to ownership

Blameless Postmortem: Key Reminders

Creating and fostering a blameless culture requires constant reinforcement before and during a post-mortem. Model a blameless mindset throughout the organization —ask better questions rather than pointing fingers.

When things go wrong, it's natural to look for someone to blame. Fighting this tendency requires practice but, most importantly, proper facilitation.

Use these tips to remove blame from your postmortems:

  • Remember the why
  • Always assume positive intent
  • Use "I" instead of "you" statements
  • Ask What? How? When? Why? rather than Who?
  • Refer to  people by role rather than name
  • Focus on the system (processes, behaviors, roles, information, etc.), not individuals
  • Stay curious – mistakes are steppingstones
  • Be patient – it takes time to get it right

Schedule a call to discuss how we can help you facilitate a Blameless Post-Mortem for your team.

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