Skip to main content

PostMortem Facilitation: Theory and Practice of "New View" Debriefings

John Allspaw (Adaptive Capacity Labs)
Tutorial Please note: to attend, your registration must include Tutorials on Monday.
Average rating: ****.
(4.50, 14 ratings)


Learning from failure is a common theme at Velocity, and many organizations strive to do so. Postmortem meetings and documents are a part of such learnings. However, leading a debriefing is not straightforward and done haphazardly can bring cultural and technical damage to an organization.

This 3-hour tutorial will cover the theory and fundamentals of the “New View” on complex systems failure and “human error”, as well as techniques for facilitating an adverse event debriefing. Attendees should walk away with a more evolved sense of accident/outage investigation and a model to explore in their own organizations.

What will be covered:

  • Theoretical foundations and limitations of generating post-hoc narratives.
  • Fundamentals of the New View: accountability, responsibility, risk, and “safety” (
  • Debriefing techniques to facilitate dialogue with diverse perspectives and potential cognitive biases
  • Plotting your exploration of dynamic fault management: the phases of anomaly response, communication, and diagnosis
  • Interviewing tips and tricks: handling defensiveness and setting the stage for a productive and blame-free environment
  • We will use case studies of known accidents and outages to discuss concepts
  • How to think about the scope, purpose, and implementation of remediation items
  • The tutorial is intended on being very interactive, and sections will require back-and-forth with the attendees on the various topics


There is a very strong suggestion to watch the 2011 Velocity 90min tutorial, “Advanced PostMortem Fu and Human Error 101” before attending this deep-dive. It’s free from O’Reilly.

Photo of John Allspaw

John Allspaw

Adaptive Capacity Labs

John has worked in systems operations for over fourteen years in biotech, government and online media. He started out tuning parallel clusters running vehicle crash simulations for the U.S. government, and then moved on to the Internet in 1997. He built the backing infrastructures at Salon, InfoWorld, Friendster, and Flickr. He is now SVP of Infrastructure and Operations at Etsy, and is the author of The Art of Capacity Planning published by O’Reilly.