Conduct Blameless Post-Mortems for Every Major Incident

This standard mandates the execution of blameless post-mortems for every significant incident, focusing on root cause analysis and preventative measures rather than assigning blame.

1. Conduct Blameless Post-Mortems for Every Major Incident:

Every significant incident must be followed by a blameless post-mortem to uncover root causes and drive improvements. This approach fosters a culture of learning and continuous improvement.

• 1.1 Root Cause Analysis:
  • 1.1.1 Focus on Systemic Issues:
    • Focus on what happened, why it happened, and how to prevent recurrence, not who is at fault.
    • Encourage a data-driven approach to identifying systemic weaknesses.
  • 1.1.2 Data-Driven Approach:
    • Ensure a structured, data-driven approach to incident reviews using templates and facilitation guides.
    • Automate the collection of relevant data.
• 1.2 Knowledge Sharing:
  • 1.2.1 Shared Documentation:
    • Document insights in a shared, easily accessible knowledge base.
    • Ensure post-mortem reports are searchable and well-organised.
  • 1.2.2 Incident Learning Sessions:
    • Host regular incident learning sessions to discuss key takeaways and trends.
    • Encourage cross-team participation in these sessions.

By conducting blameless post-mortems, organisations can drive continuous improvements and prevent recurring incidents.

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