Postmortems at Etsy 2015-11 - 02
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Postmortems at Etsy 2015-11-02
WE NEED A VOLUNTEER
https://www.flickr.com/photos/acrossthesea/4590483170 2
A BRIEF HISTORY OF POSTMORTEMS
I stand on the shoulder of giants
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A BRIEF HISTORY OF POSTMORTEMS
Lots of related vocabulary
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A Brief History of Postmortems
A BRIEF HISTORY OF POSTMORTEMS
Accident Proneness
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A BRIEF HISTORY OF POSTMORTEMS
https://www.flickr.com/photos/merixon/3823883988 7
Bad apples
A BRIEF HISTORY OF POSTMORTEMS
https://www.flickr.com/photos/rocbolt/10971856093 8
Accident Proneness and Pilot Errorduring WW2
A BRIEF HISTORY OF POSTMORTEMS
Airplane accident investigations
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A BRIEF HISTORY OF POSTMORTEMS
National Transportation Safety Board Chemical Safety Board
Healthcare NASA
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A BRIEF HISTORY OF POSTMORTEMS
The Field Guide To Understanding Human Error - Sidney Dekker
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Why we conduct Postmortems
WHY WE CONDUCT POSTMORTEMS
https://www.flickr.com/photos/jf-sebastian/2938919636 13
Human Error
WHY WE CONDUCT POSTMORTEMS
https://www.flickr.com/photos/125784453@N02/14532478664 14
Just Culture
WHY WE CONDUCT POSTMORTEMS
https://www.flickr.com/photos/yevgene/5115486524 15
Blamelessness
WHY WE CONDUCT POSTMORTEMS
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Learning Organisations
Facilitating Postmortems
FACILITATING POSTMORTEMS
The rules
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FACILITATING POSTMORTEMS
• How, not why or who • Memory is fallible • Decisions are localized • Remediation isn’t the goal - learning is • Counterfactuals are your enemy #1
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FACILITATING POSTMORTEMS
Introducing Morgue https://github.com/etsy/morgue
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FACILITATING POSTMORTEMS
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FACILITATING POSTMORTEMS
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FACILITATING POSTMORTEMS
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FACILITATING POSTMORTEMS
Step 1: Welcome everyone!
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FACILITATING POSTMORTEMS
Step 2: Organize
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FACILITATING POSTMORTEMS
Step 3: Go through the timeline
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FACILITATING POSTMORTEMS
Step 4: Ask questions regularly
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FACILITATING POSTMORTEMS
Step 5: Make note of language and emotion, revisit it
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FACILITATING POSTMORTEMS
Step 6: Optional Remediation Items
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Futher Reading and Viewing
FURTHER READING AND VIEWING
Code As Craft - Blameless Postmortems (Etsy blog post)
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FURTHER READING AND VIEWING
The Field Guide To Understanding Human Error
- Sidney Dekker(At your favourite book store)
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FURTHER READING AND VIEWING
Advanced PostMortem Fu & Human Error 101
- John Allspaw, Velocity Conf 2011 (Free from O’Reilly:
https://player.oreilly.com/videos/0636920021568)
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Let’s conduct a postmortem!
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