Blameless Post-Mortem Practices: Incident Timelines, Root Cause Analysis, and Organizational Learning

What a Post-Mortem Is and Is Not#

A post-mortem is a structured analysis of an incident conducted after the incident is resolved. Its purpose is to understand what happened, why it happened, and what changes will prevent it from happening again. It is not a blame assignment exercise. It is not a performance review. It is not a formality to check a compliance box.

The output of a good post-mortem is a set of concrete action items that improve the system. Not the humans – the system. If your post-mortem concludes with “engineer X should have been more careful,” you have failed at the process. Humans make mistakes. Systems should be designed so that human mistakes do not cause outages, and when they do, the blast radius is contained.

Incident Management Lifecycle

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Incident Lifecycle Overview#

An incident is an unplanned disruption to a service requiring coordinated response. The lifecycle has six phases: detection, triage, communication, mitigation, resolution, and review. Each has defined actions, owners, and exit criteria.

Phase 1: Detection#

Incidents are detected through three channels. Automated monitoring is best – alerts fire on SLO violations or error thresholds before users notice. Internal reports come from other teams noticing issues with dependencies. Customer reports are worst case – if users detect your incidents first, your observability has gaps.