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Post-Incident Review

After major incident: full review — timeline, causes, improvements, no blame.

90 min Advanced

Goal

Turn incident from regret into org learning — prevent recurrence.

Steps

1

Within 7 days: gather participants.

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Expected Outcome

Immediate

You find 3-5 systemic causes that'd be ignored.

Evidence base

School: Etsy Blameless Post-Mortems

Founders: John Allspaw · Etsy (2012)

Allspaw — Code as Craft blog 2012 "Blameless PostMortems and a Just Culture"; Dekker — Just Culture (2007) as philosophical source.

Frequently asked questions

How long does "Post-Incident Review" take?

This exercise takes about 90 minutes, practiced in a group in a Social format.

When will I notice the effect of "Post-Incident Review"?

You find 3-5 systemic causes that'd be ignored. In the short term: After 3 PMs, first incident type doesn't recur.

Is "Post-Incident Review" evidence-based?

Yes — it draws on Etsy Blameless Post-Mortems (John Allspaw, Etsy (2012)). Allspaw — Code as Craft blog 2012 "Blameless PostMortems and a Just Culture"; Dekker — Just Culture (2007) as philosophical source.

Is "Post-Incident Review" suitable for beginners?

Its difficulty level is: Advanced. No external tools required — it can be practiced directly inside the app.

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