To help enable a just culture, when accidents and significant incidents occur (e.g., failed deployment, production issue that affected customers), we should conduct a blameless post-mortem after the incident has been resolved.‡ Blameless post-mortems, a term coined by John Allspaw, help us examine “mistakes in a way that focuses on the situational aspects of a failure’s mechanism and the decision-making process of individuals proximate to the failure.”
