# Postmortems That Change Something

> Most reviews produce a document and no change. Why, and what to do instead.

Source: https://christwentyfour.com/blog/postmortems-that-change-something

Most postmortems change nothing. The meeting happens, a document gets written, action items get listed, and the same failure returns six months later.
Judge a postmortem by what changes afterward.

## Blame ends the investigation

Once a review looks for a person, it stops looking for a cause. It also makes the next review worse. People who expect blame report less, and later. Ask why the system allowed the failure, not why a person did the obvious thing.

## Judge the decision, not the outcome

A reasonable call with bad luck is still a reasonable call. Grading by outcome teaches people to avoid deciding. Ask what the responder knew at each step, not what you know now.

## Give every action item an owner and a date

"Improve monitoring" is a wish. "Alert on checkout error rate, one named owner, due Friday" is a task. Track it where the team's real work lives, not in a document nobody reopens.

## Write fewer, and write them well

Set a threshold for a full postmortem. Below it, file a ticket and a one-line note. Above it, build the timeline from evidence, and include what went right.
It is working when someone raises a near miss that nobody outside the team noticed.