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A Look at Looking in the Mirror: PostMortems

J. Paul Reed (Release Engineering Approaches)
Operations
Mission City Ballroom B4
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As organizations try to transition to “real-time businesses” with great concurrency between their departments and attempting continuous delivery of customer-value, failure of some sort is assured. Asking “how can failure be avoided?” isn’t as useful or relevant as focusing on “how does our organization react when failure occurs?” and “how do we create a sustainable, actionable process for remedying failure?”

In this tutorial, we’ll examine tools and techniques used by other industries (transportation, construction, manufacturing) to conduct their postmortems. We’ll also look at the cognitive biases that can find their way into a postmortem process.

General topics we’ll cover in the tutorial include:

  1. Linguistic structures for postmortem analysis (findings of facts vs. judgment)
  2. Models for postmortem analysis (“five-whys”, Cynefin, drift into failure)
  3. Example situations to illustrate several types of bias
  4. Examples of other industries’ postmortem structure
  5. Tools to assist conducting postmortems

We’ll also look at a couple of contrived examples to explore what we’ve learned.

Photo of J. Paul Reed

J. Paul Reed

Release Engineering Approaches

Build/release engineering and DevOps consultant with over a decade of experience shipping bits; O’Reilly Programming blog author; host of The Ship Show.