Every incident is expensive. A good review is how you get something back for the cost.
Blameless doesn’t mean consequence-free
A blameless review assumes people acted reasonably with the information they had. The question shifts from “who made the mistake?” to “what made the mistake easy to make?” — and that question leads to fixes that actually stick.
A simple review template
- Summary — what happened, in two or three sentences.
- Impact — who was affected, and for how long.
- Timeline — detection, response and recovery, with timestamps.
- Contributing factors — usually several, rarely one “root cause”.
- What went well — worth repeating deliberately.
- Actions — each with an owner and a due date.
Patterns across many reviews
Looking across reviews over time is where the real insight is. Common threads I’ve seen:
- Detection is slower than recovery — monitoring gaps matter more than fix speed.
- Changes without a tested rollback cause a disproportionate share of long incidents.
- Missing or outdated runbooks turn a 10-minute fix into an hour.
