The Blame Game

Tech Talk Tuesday
November 20th, 2018

Blameless Postmortems

Coined by John Allspaw
  • Assume people are doing the best they can with the information they have.
  • Create an environment where people can explain why the action made sense to them at the time.
  • See human error as an effect of deeper systematic vulnerabilities within the organization.
  • Dig deeper into what caused the problem. Use the 5 Whys technique.
  • Celebrate that organizations can only improve by constantly seeking out their systematic vulnerabilities.

What is Root Cause?

Words matter

ITIL Definition

The underlying or original cause of an incident or problem.


Can you we ever know "root cause"?

How can we make changes that improve the future?

How do we make sure we never stop learning and improving?