A brief history of postmortems, how we do them at Etsy and how to start developing a Just Culture at your organisation with postmortems.

1. Postmortems at Etsy
2015-11-02

2. WE NEED A VOLUNTEER
https://www.flickr.com/photos/acrossthesea/4590483170 2

3. A BRIEF HISTORY OF POSTMORTEMS
I stand on the shoulder of giants
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4. A BRIEF HISTORY OF POSTMORTEMS
Lots of related vocabulary
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5. A Brief History of
Postmortems

6. A BRIEF HISTORY OF POSTMORTEMS
Accident Proneness
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7. A BRIEF HISTORY OF POSTMORTEMS
https://www.flickr.com/photos/merixon/3823883988 7
Bad apples

8. A BRIEF HISTORY OF POSTMORTEMS
https://www.flickr.com/photos/rocbolt/10971856093 8
Accident Proneness and Pilot Error
during WW2

9. A BRIEF HISTORY OF POSTMORTEMS
Airplane accident investigations
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10. A BRIEF HISTORY OF POSTMORTEMS
National Transportation Safety Board
Chemical Safety Board
Healthcare
NASA
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11. A BRIEF HISTORY OF POSTMORTEMS
The Field Guide To Understanding
Human Error - Sidney Dekker
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12. Why we conduct
Postmortems

13. WHY WE CONDUCT POSTMORTEMS
https://www.flickr.com/photos/jf-sebastian/2938919636 13
Human Error

14. WHY WE CONDUCT POSTMORTEMS
https://www.flickr.com/photos/125784453@N02/14532478664 14
Just Culture

15. WHY WE CONDUCT POSTMORTEMS
https://www.flickr.com/photos/yevgene/5115486524 15
Blamelessness

16. WHY WE CONDUCT POSTMORTEMS
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Learning Organisations

17. Facilitating
Postmortems

18. FACILITATING POSTMORTEMS
The rules
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19. FACILITATING POSTMORTEMS
• How, not why or who
• Memory is fallible
• Decisions are localized
• Remediation isn’t the goal - learning is
• Counterfactuals are your enemy #1
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20. FACILITATING POSTMORTEMS
Introducing Morgue
https://github.com/etsy/morgue
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21. FACILITATING POSTMORTEMS
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22. FACILITATING POSTMORTEMS
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23. FACILITATING POSTMORTEMS
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24. FACILITATING POSTMORTEMS
Step 1: Welcome everyone!
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25. FACILITATING POSTMORTEMS
Step 2: Organize
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26. FACILITATING POSTMORTEMS
Step 3: Go through the timeline
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27. FACILITATING POSTMORTEMS
Step 4: Ask questions regularly
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28. FACILITATING POSTMORTEMS
Step 5: Make note of language and
emotion, revisit it
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29. FACILITATING POSTMORTEMS
Step 6: Optional Remediation Items
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30. Futher Reading and
Viewing

31. FURTHER READING AND VIEWING
Code As Craft - Blameless Postmortems
(Etsy blog post)
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32. FURTHER READING AND VIEWING
The Field Guide To Understanding
Human Error
- Sidney Dekker
(At your favourite book store)
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33. FURTHER READING AND VIEWING
Advanced PostMortem Fu & Human Error
101
- John Allspaw, Velocity Conf 2011
(Free from O’Reilly:
https://player.oreilly.com/videos/0636920021568)
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34. Let’s conduct a
postmortem!