This is an excerpt from the Stella Report, which is the result of the first project “Coping With Complexity” performed by the Resilience Engineering In Business-Critical Software Consortium (“SNAFUcatchers”). A video introduction to the report and the consortium is here.
4.1.2. Social issues in postmortems
Because they involve detailed examination of events, the circumstances that produced them, and the responses to them, postmortems may bring sensitive, contentious, and organizationally dangerous issues out in the open. Postmortems can reveal dysfunctions, poor performance, mixed messages, conflicts between stated intentions and incentives, etc.
Although apparently technically focused, postmortems are inherently social events. Especially for events with significant consequences, there are incentives to direct attention towards some issues and away from others. When large losses incur attention of senior management the tenor and content of the postmortem may shift away from freewheeling discourse to a more closed ended, narrowly technical discussion. Postmortems may become “stage plays” intended to assert organizational control, ratify management decisions, or localize and truncate the inquiry into circumstances and contributors. In most cases, these shifts are obvious to the more technically sophisticated staff. Repeated experience with these manipulations can generate secondary learning from events, i.e. learning that the organizational imperative is to maintain face, to stave off inquiry into sensitive topics, and to avoid entanglement with powerful outside entities.
Postmortems sometimes serve as demonstrations of due diligence. Such demonstrations may be used to ward off outside attention and intervention. Difficult (or dangerous) issues within the organization are often not addressed or addressed by encoding social features as technical ones. This is particularly true for efforts to produce social control when the organization is in turmoil or disintegrating. The resort to constructing policies and procedures is sometimes evidence of this.
There have been many expressions of interest in the social and psychological effects of post- anomaly reviews. Much of this interest revolves around avoiding 'blaming' the technical workers closely associated with the anomaly. Facilitators acknowledge that their role is to deflect criticism of individual performances and concentrate attention on technical contributors. Ironically, there is much less written about the technical aspects of post-anomaly investigation than about the need to avoid "blame and shame" for individuals. This is one indication of how fraught the post-accident setting is.
How does the learning from postmortems get spread across the organization? In almost all settings that we know of, postmortem processes are isolated and events are handled one-at-a-time and independently of others. There is little opportunity for review of other postmortems and reflection about the patterns across multiple postmortems are distinctly rare. Some firms have libraries of postmortems but there appear to be few people who have library cards and even fewer prone to check out a volume and peruse it. In some settings, this leads to large collections of inert knowledge. One person quipped that the library of incidents is a write-only memory.
A related problem is the way that the learning from postmortems is shared or not shared beyond the postmortem meeting itself. Learning is truncated at organizational boundaries -- at the departmental, divisional, corporate, and enterprise boundary the postmortem results become progressively more opaque and less useful. At the extreme, the publicly available reports about events are pale and stale when compared to what we understand to the many issues, problems, decisions, and tradeoffs that led to those events. Whether this is an essential feature of organizations is unclear but it is prominent wherever we look. Is it possible to pool these experiences and the results of deep, incisive examination of the anomalies?
We do not presently know how to prepare for and support distributed postmortem activities. Postmortems are presently treated like proprietary code. This suggests that there may be ways to play off the open source movement and the public code repository theme. Perhaps it is possible: play off of git and its prominence in code management, using it to manage both the postmortem data and the discourse that constitutes analysis and assessment of that data.
Investing in adaptive capacity is hard to do and even harder to sustain. It is clear that organizations under pressure find it hard to devote the resources needed to do frequent, thoughtful postmortems. Shortchanging investments in adaptive capacity in order to devote more effort to production may yield immediate benefits by taking on additional systemic brittleness. This is one example of the kinds of tradeoffs that are common in complex systems working settings (see also Hoffman & Woods, 2011).
References for this excerpt:
Hoffman RR, Woods DD (2011). Simon’s Slice: Five Fundamental Tradeoffs that Bound the Performance of Human Systems In Fiore SM, Harper-Sciarini M, eds. Proceedings of the 10th International Conference on Naturalistic Decision Making (NDM 2011). May 31st to June 3rd, 2011, Orlando, FL, USA. Orlando, FL: University of Central Florida.