An Incident Post-mortem

I was involved in an incident post-mortem today without realizing it! But first, a little background.

I lead the Incident Response team at Mathspace and we follow a blameless post-mortem culture as popularized by SREs. It boils down to not blaming specific person(s) seemingly responsible for an incident, but instead acknowledging that incidents are product of failure at team/org level. We then focus our efforts to pinpoint root cause and ways of preventing it from happening in the future.

Today’s post-mortem was outside of work! I had just met up with my partner at a cafe and we were walking home when she told me about her experience riding her usual bus back from work. The bus doors had barely finished closing behind her, when the driver stepped on the accelerator like it was race car. As she had not yet tightened her grip on the rails, she almost fell to the floor had it not been for assistance from another passenger on the first row. She was quite upset while telling the story. In fact, it was such a distressing event for her, that she took the time to report this driver to the authorities. That marked the end of her story.

“It doesn’t feel right”, I thought to myself. The bus driver who is the subject of wrongdoing, is not present. And there was no mention of how to prevent this from happening again. Simply following my instincts, I said: “But it seems to me, the real cause was your soft grip with assumption that all rides start smooth. Even if the driver didn’t start off like that, and instead had to immediately brake to avoid an accident, you would have fallen anyway”. This turned into a spiral of back and forth between us, in what appeared to be constant blame shifting. That was definitely not my intention, but she took it that way nonetheless. As our discourse continued, I started to reflect on my reaction to her story, and began to explain why I was concentrating on her grip so much. “You reported one person, but it won’t be the last time you come across a driver like that. It’s more beneficial to focus on what you can do to prevent this in the future, instead of only reacting to it after the fact.” I apologized for being insensitive and we ended there.

Next day, I had time to reflect on the whole thing. Stating the obvious, I had treated this just like any other incident post-mortem, which I had trained myself for, for years prior. Perhaps, the first mistake on my part, comes from doing so in absence of mutual understanding of the rules of a blameless post-mortem. Had my partner known, the intention was not to blame, she may not have been so defensive. Granted, my wording didn’t help either, as I specifically said that she had not done the right thing.

That brought into view, yet another subtlety, even in presence of people who’re onboard with blameless post-mortem: how you phrase a root cause can imply blame. Humans are not machines you can simply configure to ignore connotations of speech. In addition, what constitutes crossing the line is up for interpretation. For instance, you can tell someone you don’t mean to insult them prior to firing a series of strong curse words at them. They may have interpreted “insult” along the lines of “you’re not as smart as you look” and not outright profanity.

Somewhat related, given perfect understanding among everyone, guilt can still lurk inside the individual(s) who pushed the buttons that led to an incident. Therefore, it’s worthwhile to reiterate the blameless culture at each post-mortem and remind people that they are not alone in causing loss to the organization.

And finally, I learnt to be more sensitive and have sympathy for those affected by the incident. This can simply be shown by acknowledging that the incident has caused distress, lost hours and disruption for those involved.

I am a big proponent of applying one’s work skills to everyday life. However, one must consider the context where those skills are often applied and ensure such context is present. This can mean letting others know in advance, the reason behind your approach, in order to minimize misunderstandings later.

Similarly, I get a thrill of learning from applications of skills in wider set of problems than they were originally meant for. I still have a lot to learn and I can’t wait for more such opportunities.