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I think this response is really good.

Now that we're all not picking it, however, I think they should remove the "People" section. They did a good job of adjusting process instead of blaming people. The people section, however, might lean toward blaming people. They didn't, in this case, but it could.

2 comments

Hey there. Thanks for this feedback. I think it is important to be open honest but not blame-oriented in our review of the situation. People make mistakes and that is okay, so long as they aren't willful or due to incompetence. Neither of which was the case here. The key thing is not to create a situation where a mistake is an individuals fault. My general view is if people are making mistakes then we have done something wrong as a company and need to understand and fix the tools/training/process that led to the mistake.

I'm involved in work around reviewing medical care.

Generally, a "People" section that mentions processes not being followed is an incomplete root cause analysis.

Why was it was possible for the process not to be followed?

There's obviously a limit to how far it makes sense to drill down with why why why, but stopping at "someone didn't follow guidance" is too early.

I disagree. People are often (perhaps usually) a significant contributor to incidents and I like seeing that called out explicitly.

Internally, we want to know exactly who did what, when, and why they thought that was the right approach. We're pretty ruthless about getting those facts down; in exchange, we're beyond lenient on anything that resembles punishment of people (barring multiply repeated cases of extraordinarily poor judgment).

We don't publish post-mortems publicly (though we do internally); still, we generally elide names from the published docs (replacing with role names such as "Operator1", "SquadLead1", etc.), but internal to the teams, we really value understanding exactly what happened and don't shy away from understanding the specific people involved. It's not in any way a black mark on someone's record to have downed prod or made a problem worse. It happens; better we understand and accept that.