Purpose

This policy establishes the principles and expectations for how our team conducts post-mortems after incidents. The goal is to learn, improve, and prevent recurrence, not to assign blame.

Incidents are inevitable in complex systems. Our response determines whether they become wasted pain or fuel for resilience. This policy ensures we handle them in a way that builds trust, accelerates learning, and strengthens our systems.

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This postmortem process is blameless by design. It protects psychological safety, focuses on systemic improvement, and ensures accountability without finger-pointing.

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Core Principles

Blame-Free by Design

• Post-mortems focus on what happened and why the system allowed it, not who is at fault.
• Individual mistakes are treated as signals of systemic gaps in process, tooling, or context that need fixing.

Root Cause Focus (Systems Thinking)

• We look beyond “human error” to uncover deeper causes.
• Every incident is analyzed with the assumption that multiple contributing factors aligned.
• Ask how the system allowed this to happen, not who caused it.

Psychological Safety

• Everyone is safe to speak openly, admit mistakes, or say “I don’t know.”
• Mistakes are shared to help the team learn, not to shame or punish.
• Leaders set the tone with no finger-pointing.

Actionable Follow-Through

• Every post-mortem produces clear, prioritized action items with owners and deadlines.
• Target greater than 85 percent closure of all action items within 2 to 8 weeks, depending on priority.
• We measure success by completed improvements and reduced repeat incidents, not just completed reports.

Transparency and Sharing

• Post-mortems are visible across teams so we can learn from each other.