"postmortem" entries

The infinite hows

An argument against the Five Whys and an alternative approach you can apply.

Before I begin this post, let me say that this is intended to be a critique of the Five Whys method, not a criticism of the people who are in favor of using it. This critique I present is hardly original; most of this post is inspired by Todd Conklin, Sidney Dekker, and Nancy Leveson.

The concept of post-hoc explanation (or “postmortems” as they’re commonly known) is, at this point, taken hold in the web engineering and operations domain. I’d love to think that the concepts that we’ve taken from the new view on “human error” are becoming more widely known and that people are looking to explore their own narratives through those lenses.

I think that this is good, because my intent has always been (might always be) to help translate concepts from one domain to another. In order to do this effectively, we need to know also what to discard (or at least inspect critically) from those other domains.

The Five Whys is such an approach that I think we should discard.

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Postmortems, sans finger-pointing: The O’Reilly Radar Podcast

In this episode, John Allspaw talks in-depth about blameless postmortems and creating a just culture.

Editor’s note: you can subscribe to the O’Reilly Radar Podcast through iTunes, SoundCloud, or directly through our podcast’s RSS feed.

When you’re dealing with complex systems, failure is going to happen; it’s a given. What we do after that failure, however, strongly influences whether or not that failure will happen again. The traditional response to failure is to seek out the person responsible and punish them accordingly — should they be fired? Retrained? Moved to a different position where they can’t cause such havoc again?

John Allspaw, SVP of technical operations at Etsy and co-chair of the O’Reilly Velocity Conference, argues that this “human error” approach is the equivalent of cutting off your nose to spite your face. He explains in a blog post that at Etsy, their approach it to “view mistakes, errors, slips, lapses, etc., with a perspective of learning.” To that end, Etsy practices “blameless postmortems” that focus more on the narrative of how something happened rather than who was behind it, and that remove punishment as an outcome of an investigation.

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