Chapter 15. Postmortem Culture: Learning from Failure

The cost of failure is education.

Devin Carraway

As SREs, we work with large-scale, complex, distributed systems. We constantly enhance our services with new features and add new systems. Incidents and outages are inevitable given our scale and velocity of change. When an incident occurs, we fix the underlying issue, and services return to their normal operating conditions. Unless we have some formalized process of learning from these incidents in place, they may recur ad infinitum. Left unchecked, incidents can multiply in complexity or even cascade, overwhelming a system and its operators and ultimately impacting our users. Therefore, postmortems are an essential tool for SRE.

The postmortem concept is well known in the technology industry [All12]. A postmortem is a written record of an incident, its impact, the actions taken to mitigate or resolve it, the root cause(s), and the follow-up actions to prevent the incident from recurring. This chapter describes criteria for deciding when to conduct postmortems, some best practices around postmortems, and advice on how to cultivate a postmortem culture based on the experience we’ve gained over the years.

Google’s Postmortem Philosophy

The primary goals of writing a postmortem are to ensure that the incident is documented, that all contributing root cause(s) are well understood, and, especially, that effective preventive ...

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