Etsy Blameless Post Mortem

An Etsy blameless post-mortem evaluates mistakes by examining systemic failures rather than assigning individual fault. This sequence guides teams and individuals through timeline construction, context mapping, and preventive remediation.

5 time blocks, 45 minutes in total.

Time blocks

Construct the Incident Timeline: 10 min
List exact actions and events in chronological order without judgment
Assess Impact and Containment: 5 min
Note immediate consequences and verify all urgent fixes are active
Map Decision Context: 10 min
Document what information was available when choices were made
Identify Systemic Root Factors: 10 min
Examine tool defaults safeguards and communication gaps
Define Remediation Actions: 10 min
Write specific systemic safeguards to prevent identical failures

About this routine

Engineers at Etsy pioneered the Etsy blameless post-mortem process to change how organizations respond to operational failures and human error. Instead of reprimanding people, the approach assumes that workers act in good faith based on the information available at the time. The objective is to understand why a mistake made sense when it occurred.

The process begins with an objective timeline of events followed by a clear assessment of impact. Participants examine contributing technical and procedural factors, focusing on missing safeguards or confusing interfaces rather than personal fault.

By framing errors as design flaws in the working environment, the method turns mistakes into permanent systemic improvements. You can adapt this format for individual work or team debriefs using a routine timer online to keep each phase focused.

Why this routine works

Removes fear and defensiveness when analyzing errors
Identifies underlying process gaps and missing technical safeguards
Creates clear action items to prevent duplicate failures
Builds a reliable historic record of decisions and systemic fixes

FAQ

What is an Etsy blameless post-mortem?

It is an incident review method created to analyze mistakes by focusing on system design, missing safeguards, and contextual factors rather than personal blame.

How does a blameless post-mortem differ from an after action review?

An after action review compares planned objectives with actual outcomes, whereas a blameless post-mortem specifically assumes human error stems from systemic factors and seeks to fix underlying tools and processes.

How long does a blameless post-mortem take?

A focused session takes 45 minutes, spanning timeline creation, context mapping, systemic root cause analysis, and remediation planning.

Sources

Blameless Post-Mortems and Just Culture, Etsy Code as Craft
How Complex Systems Fail, Richard I. Cook