Postmortems at Etsy

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

Technology

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

A BRIEF HISTORY OF POSTMORTEMS
I stand on the shoulder of giants
3

A BRIEF HISTORY OF POSTMORTEMS
Lots of related vocabulary
4

A BRIEF HISTORY OF POSTMORTEMS
Accident Proneness
6

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

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

A BRIEF HISTORY OF POSTMORTEMS
Airplane accident investigations
9

A BRIEF HISTORY OF POSTMORTEMS
National Transportation Safety Board
Chemical Safety Board
Healthcare
NASA
10

A BRIEF HISTORY OF POSTMORTEMS
The Field Guide To Understanding
Human Error - Sidney Dekker
11

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

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

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

WHY WE CONDUCT POSTMORTEMS
16
Learning Organisations

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
19

FACILITATING POSTMORTEMS
Introducing Morgue
https://github.com/etsy/morgue
20

FACILITATING POSTMORTEMS
Step 1: Welcome everyone!
24

FACILITATING POSTMORTEMS
Step 2: Organize
25

FACILITATING POSTMORTEMS
Step 3: Go through the timeline
26

FACILITATING POSTMORTEMS
Step 4: Ask questions regularly
27

FACILITATING POSTMORTEMS
Step 5: Make note of language and
emotion, revisit it
28

FACILITATING POSTMORTEMS
Step 6: Optional Remediation Items
29

FURTHER READING AND VIEWING
Code As Craft - Blameless Postmortems
(Etsy blog post)
31

FURTHER READING AND VIEWING
The Field Guide To Understanding
Human Error
- Sidney Dekker 
(At your favourite book store)
32

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)
33

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Postmortems at Etsy

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 3

4. A BRIEF HISTORY OF POSTMORTEMS Lots of related vocabulary 4

5. A Brief History of Postmortems

6. A BRIEF HISTORY OF POSTMORTEMS Accident Proneness 6

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 9

10. A BRIEF HISTORY OF POSTMORTEMS National Transportation Safety Board Chemical Safety Board Healthcare NASA 10

11. A BRIEF HISTORY OF POSTMORTEMS The Field Guide To Understanding Human Error - Sidney Dekker 11

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 16 Learning Organisations

17. Facilitating Postmortems

18. FACILITATING POSTMORTEMS The rules 18

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 19

20. FACILITATING POSTMORTEMS Introducing Morgue https://github.com/etsy/morgue 20

21. FACILITATING POSTMORTEMS 21

22. FACILITATING POSTMORTEMS 22

23. FACILITATING POSTMORTEMS 23

24. FACILITATING POSTMORTEMS Step 1: Welcome everyone! 24

25. FACILITATING POSTMORTEMS Step 2: Organize 25

26. FACILITATING POSTMORTEMS Step 3: Go through the timeline 26

27. FACILITATING POSTMORTEMS Step 4: Ask questions regularly 27

28. FACILITATING POSTMORTEMS Step 5: Make note of language and emotion, revisit it 28

29. FACILITATING POSTMORTEMS Step 6: Optional Remediation Items 29

30. Futher Reading and Viewing

31. FURTHER READING AND VIEWING Code As Craft - Blameless Postmortems (Etsy blog post) 31

32. FURTHER READING AND VIEWING The Field Guide To Understanding Human Error - Sidney Dekker  (At your favourite book store) 32

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) 33

34. Let’s conduct a postmortem!

Postmortems at Etsy

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