The Post-Mortem

When working at speeds that are slightly out of your comfort zone, mistakes are inevitable. We like to say: “go faster until you break something”, or “break stuff at least 5% of the time”. This is referring to the idea that nobody is perfect, and giving yourself a forgivable margin of error allows you to move and learn a lot faster.

If we accept everyone makes mistakes, then the important question becomes: “How do we learn from mistakes?” Enter the post-mortem.

The post-mortem is an assessment of a task or project that has gone wrong. The idea is to find out the root cause and improve structurally, so the mistake can be prevented in the future. When a post-mortem is done properly this will help to better learn from mistakes, improve team efficiency, improve existing processes and work better together.


When do we do Post-Mortems?

We do post-mortems when there is no obvious cause or if there is an opportunity to learn. We also do post-mortems when there is a lack of process or when an existing process seems to have failed or wasn't followed.


How do we do Post-Mortems?

We write down the following points:

  • Impact (who was impacted by what?)
  • What happened (timeline of the events / ordered list of the facts)
  • 5 Whys
  • Why did our Quality Management process not catch this
  • Next actions / Improvements

Each section needs to be clearly answered by the people involved. A post-mortem meeting can be scheduled if necessary. The most important aspect of a post-mortem is that everyone involved needs to be honest to themselves and the team. We’re not here to point and blame, but to find and understand the root cause to improve structurally. Also see habit “Asking the 5 whys” and value of excellence.