Blameless postmortem.

also: blameless postmortems · postmortem · postmortems · post-mortem · five whys

A written review after an incident that asks why the system allowed the failure, not who erred, and ends in concrete action items.

the two-minute refresher

Goal: learn and improve, not punish.
People acted in good faith with what they knew; systems that allow human error are the cause.
Five whys: keep asking why until you reach a systemic cause.
Every postmortem ends with owned, dated action items.

also: blameless postmortems · postmortem · postmortems · post-mortem · five whys

A written review after an incident that asks why the system allowed the failure, not who erred, and ends in concrete action items.

Goal: learn and improve, not punish.
People acted in good faith with what they knew; systems that allow human error are the cause.
Five whys: keep asking why until you reach a systemic cause.
Every postmortem ends with owned, dated action items.