THE CASE: The Post-Mortem That Changed Nothing
Sanjay's team does post-mortems after every incident. Root cause analysis. Action items documented. Then filed away. Same issues repeat in 6 months. Same "root causes" identified. Same ignored action items.
The Core Insight
80% of post-mortems don't lead to action (PagerDuty). Blameless post-mortems: 60% higher follow-through. The goal isn't documentation—it's preventing repeat failures.
The Evidence
80% don't lead to action (PagerDuty)
Blameless = 60% higher follow-through (Google SRE)
Tracked actions: 40% fewer repeat incidents
The Effective Post-Mortem Framework
Blameless Post-Mortem Rules
- No blame, no shame. People aren't the root cause—systems are
- 5 Whys. Keep asking until you hit systemic cause
- Action items with owners and deadlines. No vague "we should..."
- Follow-up review. Were actions completed? Did they work?
The Experiment
Review post-mortems from last 6 months. Track: How many action items were completed? How many issues repeated? Institute follow-up reviews.
Sources
- PagerDuty. Post-Mortem Effectiveness Study. 2023.
- Google SRE. Blameless Post-Mortems. 2022.
Key Takeaways
- 80% of post-mortems don't lead to action—they're theater
- Blameless culture leads to 60% higher follow-through
- Assign owners, set deadlines, schedule follow-up reviews