Running an incident review without looking for someone to blame

I'm a software engineer during the week, so the meeting after something broke is a familiar one. Something went down, customers noticed, it is fixed now, and the team is in a room on Monday to review it. Everybody has read that the review should be blameless and everybody agrees, and the first question still lands on one person, because the pull towards finding out who did it is stronger than any principle written down about it.

Running a post-incident review without looking for someone to blame is one of the eight scenarios on the Management Lab list. This is an invented version of it, played the way the Lab would play it. The people and the firm are made up.

The situation

Morag leads a team of seven at a mid-sized firm. On Friday afternoon a change went out and for two hours nobody could log in. Jamie made the change. Dev approved it without reading it properly, because it was Friday and it was small. The check that would have caught it was switched off in the summer and nobody switched it back on, and three people knew that. By Monday morning everyone in the team knows Jamie made the change, and Jamie knows that everyone knows. Morag has booked the room for an hour, and there are people above her who want to hear that it has been dealt with.

The first line of the post-incident review, and what it does

Morag starts the way a lot of incident reviews start. "Right. Jamie, do you want to talk us through what happened?"

In the Lab I would stop the scene there. The line named one person in its first sentence, and everyone else in the room heard that the review had already found its answer. Jamie sits up and begins, and what comes out is a defence, because when you are handed the floor with your name on it that is what the floor is for. Dev, who approved the change, relaxes a little, and so do the three people who knew about the switched-off check. None of them are hiding anything. The shape of the question has told them that their part is not what the meeting is about.

The review runs for an hour, produces a timeline of what Jamie did, and ends with Jamie agreeing to be more careful. The check stays off and Friday changes carry on, so the next incident is already possible, and the person who could have told the room most about it has spent the hour making sure it wasn't their fault.

The line that makes a blameless review possible

The same pair pick it up from the same point and try something different. "Something got through on Friday and I want to understand what made that possible. I'll go first. I knew the check was off and I didn't chase it."

There is no name in the first sentence, so nobody has been told who the meeting is about. "What made that possible" asks for several answers, where "what happened" with a name attached asks for one. Morag has also put her own part on the table before anyone else's, which shows the room what kind of contribution she wants and makes it possible to give one. Dev goes next, because Dev now can, and when it comes round to Jamie, Jamie is describing a change instead of defending one.

The people who were closest to the incident know the most about it, and whether they say what they know depends on how the first line was put.

What the swap shows

Then they change sides. Morag plays Jamie, and the other manager gives her the first line back. "Jamie, do you want to talk us through what happened?"

She finds she has started building a defence before the sentence is finished. She came into the room with three things she noticed on Friday, the check among them, and she cannot say any of them, because the first job is to get through the question with her name intact. What she knows gets filed for later, and later does not come, because by then the room has its answer. She has spent two minutes as Jamie and felt where the information went.

"Do you want to" also turns out to be a courtesy that does not survive the room. Everyone else hears it as an instruction, and the person it is aimed at hears it as a verdict with a polite front on it. From Jamie's chair the politeness makes it worse, because it means the manager knows what she is doing.

What the Lab does with it

The rule in the room is that we talk about lines, never people. Feedback is about what a sentence did to the conversation, and nobody's manner is discussed, which is the same discipline a blameless review asks for, applied to the review of the scene. A manager who has heard "talk us through what happened" from Jamie's chair has a better reason to open differently on Monday than any principle they have read. This scenario is one of eight and the group picks its own on the day. If your incident reviews keep ending with one person agreeing to be more careful, the price of three hours in the Lab is on the rate card.