The Meeting Where Nobody Should Be Named

Subtitle: A post-mortem is a shape, not a mood.

• Left column - Part one: the timeline:
• UTC rows, one per observable event
• What the system did, what a human did
• No verbs of intent, ever
• Evidence: 14:06 error rate crossed 2%
• Story: she forgot to check

• Right column - Part two: the counterfactual:
• Ask it of every proposed cause
• Prevented if this one thing differed?
• If no, it is context, not a cause
• Context moves back to the timeline
• Conclusions stay short and few

• Part three - actions that count:
• Every action: one owner, one date
• Change a system or a default
• Never change someone's diligence

• Why blameless is load-bearing:
• Naming a person is not rude, it is lossy
• The people who know most go quiet
• Assume each person acted reasonably
• Ask what made the wrong action look right

• Audit your own document:
• Count actions owned by a behaviour
• Be more careful is a wish, not a fix
• Wishes launder blame into process
• Re-open at 30 days: what shipped?
• Nothing shipped, expensive ritual

• One cause is a warning sign:
• Complex systems need several conditions
• Exactly one cause: stopped at the first
• Untouched conditions cause the next one

Taped rule strip: Two questions - does it name a person, and did anything ship?