From the just-culture work of Sidney Dekker (Just Culture, 2007) and John Allspaw (Blameless PostMortems and a Just Culture, 2012); Google's practice is set out by Betsy Beyer, Chris Jones, Jennifer Petoff, and Niall Richard Murphy, eds. (Site Reliability Engineering, 2016).
Reviews an incident on the premise that people acted reasonably on what they knew, so the account surfaces system and process causes and produces owned action items.
When to reach for it
Right after an outage, failure, or near miss, when a review that hunts for someone to blame would hide what actually went wrong.
How it runs
- Meet within a few days, once responders have rested.
- Appoint a facilitator to hold the no-blame rule.
- Rebuild the timeline with what each person knew at the time.
- Find contributing causes in technology, process, and organization.
- Assign action items with owners and dates.
- Publish the write-up widely.
Where it sits in SOLVE eX
Go to the source
- Just Culture: Balancing Safety and Accountability, 2007
- Blameless PostMortems and a Just Culture, Etsy Code as Craft, 2012
- Site Reliability Engineering: How Google Runs Production Systems, O'Reilly, 2016