How to Run a Post-Mortem With Humans (Not Robots)

Uh-oh.

Something Very Bad has happened at your organization. The immediate fire has been put out (maybe some cinders are still smoldering), but now it’s time to get some people into a room and figure out a) how on earth did that happen, and b) how do we make sure it never, ever happens again.

Congratulations, you’re running a post-mortem.

This talk addresses the deep challenges that you’re going to face when you have a roomful of human beings ashamed about some Bad Thing that they were a part of. And, once you understand those challenges, it explains how you can overcome them (spoiler: humor is critical).

It knits together ideas from psychology (e.g. various kinds of ‘cognitive biases’; how the moral instinct works in humans; what humor is and how it functions; etc), with personal experience both running a wide variety of post-mortems, and also building a lot of systems that have failed (sometimes spectacularly).

This talk aims to give you a vision of how crazy valuable an effective post-mortem process can be, plus a wide variety of specific tactics to improve your own practice.

Some topics addressed:

• The profound, warping influence of shame (and why it’s so hard to avoid)
• How to recognize the moral mindset, and how to move a team beyond it
• Tips for defeating hindsight bias (direct, merciless mockery is the key)
• The promises and the problems of the “5 Whys” approach
• Why it’s so hard to get an organization to actually invest in fixes/corrective actions/remediations
• How to build a culture of post-mortems at a company (in particular, if you have a good-sized company, which does not currently have such a culture)
• Specific tips for learning the skill of leading post-mortems

Everyone seems to agree that learning from failure is hugely important, but it can be a surprisingly hard thing to do.