After every operational failure, run five blameless…
After any operational failure, write a blameless post-mortem using five questions: what happened (factual description), what was the timeline of contributing events, what were the systemic factors, what are the action items (specific system changes), and what would have prevented this.
When This Fires
- After any system, process, or operational failure (missed deadline, broken deployment, dropped commitment)
- After a near-miss that could have been a failure under slightly different conditions
- When the same type of failure recurs, signaling unresolved systemic factors
- During any incident review or retrospective
Common Failure Mode
Stopping at question 1 ("what happened") and jumping to action items without analyzing the timeline or systemic factors. The resulting action items address the immediate trigger but not the systemic conditions that produced it, so the failure recurs in a slightly different form.
The Protocol
After any operational failure: (1) Write a factual description of what happened (no blame, no interpretation). (2) Construct the timeline of contributing events — trace backward from the failure to identify each contributing factor. (3) Identify systemic factors: what about the system's design made this failure possible? (4) Write specific action items — system changes, not behavior changes. "Add automated check before deployment" not "be more careful when deploying." (5) State what single change would have most likely prevented this failure. That's your highest-leverage improvement.