Post-mortem Fail
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Post-mortems are crucial for learning and improving processes but often fail due to psychological and organizational barriers such as fear of blame and groupthink. Teams may espouse belief in their value while not implementing them due to resistance to outside feedback and hierarchical pressures. To succeed, post-mortems must be structured as blame-free discussions aimed at understanding failures without fear of punishment.
Post-mortem Fail
- 1. POST-MORTEM 6 REASONS YOUR PROCESS ISN’T WORKING FAIL
- 2. SO WHY DON’T MORE TEAMS DO THEM? 100% of teams want to do post-mortems. The research supports that post-mortems are an effective way of improving your company’s processes. Post-mortems provide an opportunity to learn. sources: http://www.ponemon.org/library/2013-cost-of-data-center-outages 01
- 3. Add to that the fact that there is always an element of accountability associated with the post-mortem. If you were the on-call person, it can be especially difficult to find fault with your own work. You thought you were doing the right thing at the time, but taking the sole responsibility for those decisions (and hearing what others thought of your actions in the firefight) can be especially emotional. Looking objectively at your own decision-making prowess is essential for a successful post-mortem. source: McAvoy J (2006) “Evaluating the Evaluations: Preconceptions of Project Post-Mortems” The Electronic Journal Information Systems Evaluation Volume 9 Issue 2, pp 65 - 72 TALKING ABOUT WHAT HAPPENED DURING AN OUTAGE IS HARD Six reasons your process isn’t working POST-MORTEMS FAIL BECAUSE... 0 2
- 4. Kwak and Stoddard (2003) attribute this failing to the propensity within companies to “shoot the messenger.” No one wants to be the bearer of bad news (who likes that person?) and this deters people from reporting problems. PEOPLE ARE MORE PRONE TO COVERING UP THEIR MISTAKES THAN HIGHLIGHTING THEM. source: McAvoy J (2006) “Evaluating the Evaluations: Preconceptions of Project Post-Mortems” The Electronic Journal Information Systems Evaluation Volume 9 Issue 2, pp 65 - 72 Six reasons your process isn’t working POST-MORTEMS FAIL BECAUSE... 03
- 5. 03 YOU TALK MORE ABOUT POST-MORTEMS THAN ACTUALLY DOING THEM source: McAvoy J (2006) “Evaluating the Evaluations: Preconceptions of Project Post-Mortems” The Electronic Journal Information Systems Evaluation Volume 9 Issue 2, pp 65 - 72 Six reasons your process isn’t working Espoused theories are the beliefs that we describe ourselves as having – in this case the project members described how they believe in the value of post-mortems. Theories in use guide how we actually behave – what actually guides us as opposed to what we profess to guiding us. 100% of those surveyed espoused their belief in the usefulness of project post-mortems, yet half of these did not translate these espoused beliefs into actual use. POST-MORTEMS FAIL BECAUSE... 04
- 6. “ My team knows what the problems in the project were and what to do to fix them. There is no point in involving others as they will only add overhead rather than helping to fix the problems.” This attitude is one of the quickest ways to stagnate and ensure that you repeat mistakes. Sometimes you need someone outside of the problem (and your team) to help you see things clearly. source: McAvoy J (2006) “Evaluating the Evaluations: Preconceptions of Project Post-Mortems” The Electronic Journal Information Systems Evaluation Volume 9 Issue 2, pp 65 - 72 Six reasons your process isn’t working YOU DON’T THINK YOU NEED ANY OTHER FEEDBACK. POST-MORTEMS FAIL BECAUSE... 05
- 7. Peer groupthink originates in a need for conformity and close integration within a team. Symptoms of groupthink include: little or no consideration of alternate plans, risk is not reassessed, no review is taken of rejected plans, advice from outsiders is not sought, facts that support the plan are acknowledged - facts that do not support the plan are ignored, and contingency plans are not created. Groupthink is defined by its originator Janis(1972, p.9) as: “ a deterioration of mental efficiency, reality testing, and moral judgement that results from in-group pressures.” YOU’RE SUFFERING FROM PEER GROUPTHINK. POST-MORTEMS FAIL BECAUSE... Six reasons your process isn’t working source: McAvoy J (2006) “Evaluating the Evaluations: Preconceptions of Project Post-Mortems” The Electronic Journal Information Systems Evaluation Volume 9 Issue 2, pp 65 - 72 06
- 8. If your leader doesn’t believe in post-mortems, then it’s going to be very difficult to have a successful one (or even begin to convince your boss that you actually need to be doing them). Hierarchical groupthink originates in a desire to please a leader, specifically the desire not to disagree with them. Hierarchical groupthink is shown to have a negative impact on the team members’ impression of post-mortems, even though project members espouse a positive view in the survey. This hierarchical groupthink tends to convince team members that the process itself is not valuable – it would even be portrayed as a waste of time. YOU’RE SUFFERING FROM HIERARCHICAL GROUPTHINK. POST-MORTEMS FAIL BECAUSE... Six reasons your process isn’t working source: McAvoy J (2006) “Evaluating the Evaluations: Preconceptions of Project Post-Mortems” The Electronic Journal Information Systems Evaluation Volume 9 Issue 2, pp 65 - 72 07
- 9. EVERYONE IS HUMAN... UNLESS YOU HIRED A ROBOT. OTHER PSYCHOLOGICAL & SOCIOLOGICAL FACTORS TO TAKE INTO CONSIDERATION: Trust • means that mistakes aren’t punishable acts but opportunities to learn • means that everyone on the team will jump in to help rather than complain when there’s a problem Stress • is caused by the worry of being negatively judged • encompasses health issues, relationship problems and sleep • is different for everybody and everybody reacts differently to it Fear • of losing their job • of finger-pointing, blame & guilt • of costing the company money • of never getting the chance to work on something interesting again Six reasons your process isn’t working Humans are generally well-intentioned but during an outage, this view can change fast. Being under pressure, it’s easy to put blame on someone. Before you start finger-pointing, take a minute and practice empathy. How would you feel if it was you in the same situation? 08
- 10. THE AWESOME POST-MORTEM FRAMEWORK Set the context. • Failure is a normal part of functioning of complex systems. All systems fail, it’s just a matter of time. • The purpose of the postmortem is to learn. No one will be blamed, shamed or punished for providing an account of what happened. Blame-free does not mean accountability-free. In fact, blame-free postmortems are the only way to collect full accounts of what happened. • Remind participants that during the postmortem they will be under the influence of cognitive biases. The most common ones are hindsight, outcome, and recency biases; and fundamental attribution error. We may not notice that we’re under the influence, so request—and give permission—for biases to be called out during the postmortem. Build a timeline. • We want to understand what happened from the perspective of the individuals involved: what did they know, when, and why it made sense? • Describe what happened, don’t explain. • The more diverse points of view that you can collect, the fuller the picture of the incident. Encourage and note divergent & dissenting opinions. • As the facilitator, your job is to “listen to discover and verify by synthesizing”. Determine and prioritize remediation items. Publish the postmortem write-up as widely as possible. Six reasons your process isn’t working 1 2 3 4 09
- 11. RESOURCES: Tools for the next incident, just in case. Six reasons your process isn’t working 10
- 12. VictorOps post-mortem reporting feature-http:// victorops.force.com/knowledgebase/articles/Getting_Started/Post-Mortem-Reports/ http://www.paperplanes.de/2014/6/20/what-blameless-postmortem-taught-me.html http://www.slideshare.net/jhand2/its-not-your-fault-blameless-post-mortems http://codeascraft.com/2012/05/22/blameless-postmortems/ http://www.slideshare.net/fattofatt/post-mortem-report http://www.cdlib.org/cdlinfo/2010/11/17/the-project-post-mortem-a-valuable-tool-for-continuous-improvement/ https://speakerdeck.com/indec/fallible-humans-dealing-with-failure-in-the-absence-of-scapegoats http://tech.blog.box.com/2014/08/a-tale-of-postmortems/ The Field Guide to Understanding Human Error, Sidney Dekker The Human Side of Postmortems, Dave Zwieback Six reasons your process isn’t working 11