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

Dan Milstein (Wayfair)
Velocity Culture, Grand Ballroom ABCD
Presentation: external link
Average rating: ****.
(4.48, 33 ratings)


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.


Photo of Dan Milstein

Dan Milstein


Dan Milstein is Director of Supply Chain Engineering at Wayfair, in Boston. His teams build all kinds of systems to support the physical movement of goods — which turns out to engender a marvelously hard and satisfying series of challenges. Before he joined Wayfair, he worked a programmer, architect, team lead and product owner at a variety of startups over the last 20 years. In general, he is deeply fascinated by the interactions between complex systems and the humans who build and maintain those systems.

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Brant Strand
07/10/2013 4:38am PDT

@Aminie, Dan posted this link to his deck on Twitter:

Aminie Elsberry
06/21/2013 6:30am PDT

Are the slides for this presentation posted anywhere? Loved the presentation and would like to share it with co-workers. Thanks!


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