postmortem-writing
寫出 blameless postmortem，含根因分析、時間軸與行動項目
中文翻譯
--- name: postmortem-writing description: 撰寫有效的 blameless postmortem，包含根因分析、時間軸與行動項目。在進行事件檢討、撰寫 postmortem 文件或改善事件應變流程時使用。 --- # Postmortem Writing 撰寫有效的 blameless postmortem 的完整指南，用來推動組織學習並防止事件再次發生。 ## When to Use This Skill - 進行事後事件檢討 - 撰寫 postmortem 文件 - 主持 blameless postmortem 會議 - 找出根因與促成因素 - 建立可執行的後續項目 - 建立組織的學習文化 ## Core Concepts ### 1. Blameless Culture | Blame-Focused | Blameless | | ------------------------ | --------------------------------- | | 「這是誰造成的？」 | 「是什麼條件讓這件事會發生？」 | | 「有人犯了錯」 | 「系統允許了這個錯誤」 | | 懲罰個人 | 改善系統 | | 隱藏資訊 | 分享學到的事 | | 不敢發言 | 心理安全感 | ### 2. Postmortem Triggers - SEV1 或 SEV2 事件 - 影響客戶、超過 15 分鐘的停機 - 資料遺失或資安事件 - 差點釀成嚴重後果的 near-miss - 全新的失效模式 - 需要非常規介入的事件 ## Quick Start ### Postmortem Timeline ``` Day 0: Incident occurs Day 1-2: Draft postmortem document Day 3-5: Postmortem meeting Day 5-7: Finalize document, create tickets Week 2+: Action item completion Quarterly: Review patterns across incidents ``` ## Templates and detailed worked examples 完整的範本庫與詳細的範例放在 `references/details.md`。需要具體範本時，再去讀那個檔案。 ### Template 2: 5 Whys Analysis ```markdown # 5 Whys Analysis: [Incident] ## Problem Statement Payment service experienced 47-minute outage due to database connection exhaustion. ## Analysis ### Why #1: Why did the service fail? **Answer**: Database connections were exhausted, causing all new requests to fail. **Evidence**: Metrics showed connection count at 100/100 (max), with 500+ pending requests. --- ### Why #2: Why were database connections exhausted? **Answer**: Each incoming request opened a new database connection instead of using the connection pool. **Evidence**: Code diff shows direct `DriverManager.getConnection()` instead of pooled `DataSource`. --- ### Why #3: Why did the code bypass the connection pool? **Answer**: A developer refactored the repository class and inadvertently changed the connection acquisition method. **Evidence**: PR #1234 shows the change, made while fixing a different bug. --- ### Why #4: Why wasn't this caught in code review? **Answer**: The reviewer focused on the functional change (the bug fix) and didn't notice the infrastructure change. **Evidence**: Review comments only discuss business logic. --- ### Why #5: Why isn't there a safety net for this type of change? **Answer**: We lack automated tests that verify connection pool behavior and lack documentation about our connection patterns. **Evidence**: Test suite has no tests for connection handling; wiki has no article on database connections. ## Root Causes Identified 1. **Primary**: Missing automated tests for infrastructure behavior 2. **Secondary**: Insufficient documentation of architectural patterns 3. **Tertiary**: Code review checklist doesn't include infrastructure considerations ## Systemic Improvements | Root Cause | Improvement | Type | | ------------- | --------------------------------- | ---------- | | Missing tests | Add infrastructure behavior tests | Prevention | | Missing docs | Document connection patterns | Prevention | | Review gaps | Update review checklist | Detection | | No canary | Implement canary deployments | Mitigation | ``` ### Template 3: Quick Postmortem (Minor Incidents) ```markdown # Quick Postmortem: [Brief Title] **Date**: 2024-01-15 | **Duration**: 12 min | **Severity**: SEV3 ## What Happened API latency spiked to 5s due to cache miss storm after cache flush. ## Timeline - 10:00 - Cache flush initiated for config update - 10:02 - Latency alerts fire - 10:05 - Identified as cache miss storm - 10:08 - Enabled cache warming - 10:12 - Latency normalized ## Root Cause Full cache flush for minor config update caused thundering herd. ## Fix - Immediate: Enabled cache warming - Long-term: Implement partial cache invalidation (ENG-999) ## Lessons Don't full-flush cache in production; use targeted invalidation. ``` ## Facilitation Guide ### Running a Postmortem Meeting ```markdown ## Meeting Structure (60 minutes) ### 1. Opening (5 min) - Remind everyone of blameless culture - "We're here to learn, not to blame" - Review meeting norms ### 2. Timeline Review (15 min) - Walk through events chronologically - Ask clarifying questions - Identify gaps in timeline ### 3. Analysis Discussion (20 min) - What failed? - Why did it fail? - What conditions allowed this? - What would have prevented it? ### 4. Action Items (15 min) - Brainstorm improvements - Prioritize by impact and effort - Assign owners and due dates ### 5. Closing (5 min) - Summarize key learnings - Confirm action item owners - Schedule follow-up if needed ## Facilitation Tips - Keep discussion on track - Redirect blame to systems - Encourage quiet participants - Document dissenting views - Time-box tangents ``` ## Anti-Patterns to Avoid | Anti-Pattern | Problem | Better Approach | | ----------------------- | -------------------------- | ------------------------------- | | **Blame game** | 讓學習停擺 | 專注在系統 | | **Shallow analysis** | 無法防止再次發生 | 問五次「為什麼」 | | **No action items** | 浪費時間 | 一定要有具體的下一步 | | **Unrealistic actions** | 永遠做不完 | 把範圍縮到做得到的任務 | | **No follow-up** | 行動項目被遺忘 | 在工單系統裡追蹤 | ## Best Practices ### Do's - **立刻開始** - 記憶消退得很快 - **要具體** - 精確的時間、精確的錯誤 - **附上圖表** - 視覺化的證據 - **指定負責人** - 不要有沒人認領的行動項目 - **廣泛分享** - 組織學習 ### Don'ts - **不要點名羞辱** - 絕對不要 - **不要跳過小事件** - 它們會揭露模式 - **不要把它寫成究責文件** - 那會扼殺學習 - **不要製造瑣事** - 行動項目要有意義 - **不要跳過後續追蹤** - 驗證行動項目有完成
英文原文
--- name: postmortem-writing description: Write effective blameless postmortems with root cause analysis, timelines, and action items. Use when conducting incident reviews, writing postmortem documents, or improving incident response processes. --- # Postmortem Writing Comprehensive guide to writing effective, blameless postmortems that drive organizational learning and prevent incident recurrence. ## When to Use This Skill - Conducting post-incident reviews - Writing postmortem documents - Facilitating blameless postmortem meetings - Identifying root causes and contributing factors - Creating actionable follow-up items - Building organizational learning culture ## Core Concepts ### 1. Blameless Culture | Blame-Focused | Blameless | | ------------------------ | --------------------------------- | | "Who caused this?" | "What conditions allowed this?" | | "Someone made a mistake" | "The system allowed this mistake" | | Punish individuals | Improve systems | | Hide information | Share learnings | | Fear of speaking up | Psychological safety | ### 2. Postmortem Triggers - SEV1 or SEV2 incidents - Customer-facing outages > 15 minutes - Data loss or security incidents - Near-misses that could have been severe - Novel failure modes - Incidents requiring unusual intervention ## Quick Start ### Postmortem Timeline ``` Day 0: Incident occurs Day 1-2: Draft postmortem document Day 3-5: Postmortem meeting Day 5-7: Finalize document, create tickets Week 2+: Action item completion Quarterly: Review patterns across incidents ``` ## Templates and detailed worked examples Full template library and detailed worked examples live in `references/details.md`. Read that file when you need the concrete templates. ### Template 2: 5 Whys Analysis ```markdown # 5 Whys Analysis: [Incident] ## Problem Statement Payment service experienced 47-minute outage due to database connection exhaustion. ## Analysis ### Why #1: Why did the service fail? **Answer**: Database connections were exhausted, causing all new requests to fail. **Evidence**: Metrics showed connection count at 100/100 (max), with 500+ pending requests. --- ### Why #2: Why were database connections exhausted? **Answer**: Each incoming request opened a new database connection instead of using the connection pool. **Evidence**: Code diff shows direct `DriverManager.getConnection()` instead of pooled `DataSource`. --- ### Why #3: Why did the code bypass the connection pool? **Answer**: A developer refactored the repository class and inadvertently changed the connection acquisition method. **Evidence**: PR #1234 shows the change, made while fixing a different bug. --- ### Why #4: Why wasn't this caught in code review? **Answer**: The reviewer focused on the functional change (the bug fix) and didn't notice the infrastructure change. **Evidence**: Review comments only discuss business logic. --- ### Why #5: Why isn't there a safety net for this type of change? **Answer**: We lack automated tests that verify connection pool behavior and lack documentation about our connection patterns. **Evidence**: Test suite has no tests for connection handling; wiki has no article on database connections. ## Root Causes Identified 1. **Primary**: Missing automated tests for infrastructure behavior 2. **Secondary**: Insufficient documentation of architectural patterns 3. **Tertiary**: Code review checklist doesn't include infrastructure considerations ## Systemic Improvements | Root Cause | Improvement | Type | | ------------- | --------------------------------- | ---------- | | Missing tests | Add infrastructure behavior tests | Prevention | | Missing docs | Document connection patterns | Prevention | | Review gaps | Update review checklist | Detection | | No canary | Implement canary deployments | Mitigation | ``` ### Template 3: Quick Postmortem (Minor Incidents) ```markdown # Quick Postmortem: [Brief Title] **Date**: 2024-01-15 | **Duration**: 12 min | **Severity**: SEV3 ## What Happened API latency spiked to 5s due to cache miss storm after cache flush. ## Timeline - 10:00 - Cache flush initiated for config update - 10:02 - Latency alerts fire - 10:05 - Identified as cache miss storm - 10:08 - Enabled cache warming - 10:12 - Latency normalized ## Root Cause Full cache flush for minor config update caused thundering herd. ## Fix - Immediate: Enabled cache warming - Long-term: Implement partial cache invalidation (ENG-999) ## Lessons Don't full-flush cache in production; use targeted invalidation. ``` ## Facilitation Guide ### Running a Postmortem Meeting ```markdown ## Meeting Structure (60 minutes) ### 1. Opening (5 min) - Remind everyone of blameless culture - "We're here to learn, not to blame" - Review meeting norms ### 2. Timeline Review (15 min) - Walk through events chronologically - Ask clarifying questions - Identify gaps in timeline ### 3. Analysis Discussion (20 min) - What failed? - Why did it fail? - What conditions allowed this? - What would have prevented it? ### 4. Action Items (15 min) - Brainstorm improvements - Prioritize by impact and effort - Assign owners and due dates ### 5. Closing (5 min) - Summarize key learnings - Confirm action item owners - Schedule follow-up if needed ## Facilitation Tips - Keep discussion on track - Redirect blame to systems - Encourage quiet participants - Document dissenting views - Time-box tangents ``` ## Anti-Patterns to Avoid | Anti-Pattern | Problem | Better Approach | | ----------------------- | -------------------------- | ------------------------------- | | **Blame game** | Shuts down learning | Focus on systems | | **Shallow analysis** | Doesn't prevent recurrence | Ask "why" 5 times | | **No action items** | Waste of time | Always have concrete next steps | | **Unrealistic actions** | Never completed | Scope to achievable tasks | | **No follow-up** | Actions forgotten | Track in ticketing system | ## Best Practices ### Do's - **Start immediately** - Memory fades fast - **Be specific** - Exact times, exact errors - **Include graphs** - Visual evidence - **Assign owners** - No orphan action items - **Share widely** - Organizational learning ### Don'ts - **Don't name and shame** - Ever - **Don't skip small incidents** - They reveal patterns - **Don't make it a blame doc** - That kills learning - **Don't create busywork** - Actions should be meaningful - **Don't skip follow-up** - Verify actions completed