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What is a mistake?
A mistake is a decision or judgement that led to a negative outcome, which could have been prevented with the knowledge and resources available at the time.
Post mortem
• Bring together people from all affected departments
• Collect a timeline of events
• Find the root cause
• Define actions
Anti-Pattern:Hiding mistakes
• CEO Disease
• Wasted learning opportunity
• Sets the wrong example
• Financial bonus often leads to hiding mistakes
Pattern: Proactive communication
• Be open about the failure
• Now have a post-mortem
• Talk about what was learned
Anti-Pattern:Blaming
• People get defensive
• Aggression and fear disable learning
• Root cause gets hidden
Pattern: Accepting
• A post mortem is NOT a performance review
• Focus on events, not on (groups of) people
• Prime directive
The Prime Directive
Regardless of what we discover, we understand and truly believe that everyone did the best job they could, given what they knew at the time, their skills and abilities, the resources available, and the situation at hand.
--Norm Kerth, Project Retrospectives: A Handbook for Team Reviews
Anti-Pattern:Arc of Escalation
• You play Chinese Whispers
• You force a blame game
• You destroy trust
Pattern: Talk to your peers
• Be aware of confirmation bias
• They are nice guys, really!
• Try to switch perspectives
Anti-Pattern:Cowardice
• Time wasted on formalities
• No one wants to be responsible
• Cause: punishing or firing people who screw up
Predicting Failure aka Pre mortem
• Gather groups of people from different departments
• Start with a catastrophic outcome
• Have fun
• Rinse. Repeat.
Contact me!
Oliver Hankeln Freelance DevOps & Agile Evangelist
@mydalon
Image sources• Copper ore: http://commons.wikimedia.org/wiki/File%3ANatural_Copper_Ore_Macro_1.JPG; Jonathan Zander; CC-BY-
SA-3.0, via Wikimedia Commons
• Post mortem: http://catalogue.wellcomelibrary.org/record=b1102466; Photo number: L0075723; Wellcome Trust; CC-BY-4.0
• Boys at the lake: http://commons.wikimedia.org/wiki/File%3ABundesarchiv_Bild_102-00651%2C_Berlin%2C_Strandbad_Wannsee.jpg ; Bundesarchiv, Bild 102-00651 / CC-BY-SA; via Wikimedia Commons
• Hand: https://openclipart.org/detail/192388/nice-manicule, public domain
• Prairie dogs: http://upload.wikimedia.org/wikipedia/commons/a/a9/Kissing_Prairie_dog_edit_3.jpg; IBrocken Inaglory,;CC-BY-SA-3.0; via Wikimedia Commons
• Nuclear test: https://commons.wikimedia.org/wiki/File%3A%22Ivy_Mike%22_atmospheric_nuclear_test_-_November_1952_-_Flickr_-_The_Official_CTBTO_Photostream.jpg; By The Official CTBTO Photostream; CC-BY-2.0; via Wikimedia Commons
• Talking men: https://commons.wikimedia.org/wiki/File%3AFotothek_df_ps_0000147_Zwei_alte_Herren_im_Gespr%C3%A4ch.jpg; Deutsche Fotothek; CC-BY-SA 3.0-de; via Wikimedia Commons
• Paperwork:http://commons.wikimedia.org/wiki/File:Lightmatter_paperwork.jpg; AaronLogan; CC-BY 2.5 Generic; vie Wikimedia Commons
• Buzz Aldrin on the moon: https://commons.wikimedia.org/wiki/File:Aldrin_Apollo_11_(jha).jpg; NASA, public domain; vie Wikimedia Commons
• Crystal ball: http://de.wikipedia.org/wiki/Datei:John_Dee_s_Seal_Kristallkugel.jpg ; User „Steevie", CC-BY-SA 3.0/de