Systems Safety approach to incident learning emphasizing organizational learning over blame and individual fault-finding
Etsy's Blameless Postmortem process transformed how the tech industry learns from failures. By removing blame and focusing on systems, teams can discuss failures openly and prevent recurrence.
The template includes structured sections: timeline of events (facts, not interpretation), what went well (reinforcing good practices), what went wrong (without assigning blame), where we got lucky (near-misses to address), and action items (specific, assigned, tracked).
Key principles include assuming everyone did their best with available information, focusing on how rather than who, treating failure as a learning opportunity, and making postmortems a celebration of learning, not punishment.
The facilitation guide covers running effective debriefs, creating psychological safety for honest discussion, avoiding counterfactuals and blame language, and turning incidents into organizational learning.
This approach dramatically improves incident response by encouraging early escalation without fear, building a culture of continuous improvement, preventing repeat incidents through systemic fixes, and creating institutional memory of failure modes. Teams using blameless postmortems report faster incident resolution and fewer repeat failures.
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