Something about this feels wrong:

- If you trust them completely, you don't need to know what happens next either. Just trust them to do the right things, your leadership isn't required.

- If you don't trust them completely, how can you know if "what happens next" is appropriate without knowing the details?

Isn't this just reinforcing the idea that leadership doesn't need to have their feet on the ground?

The best leaders I've worked with were paying attention to things from the bottom-up as well as top-down.

In the running example I think it is clear that you could stop at any point and address the problem from that point rather than continuing. Questions such as "Why do we permit last minute changes at all?" are given no space.

In a complex system sometimes there is no root cause (cf. aviation crash investigations and the Swiss Cheese nature of risk). By allowing one person to shoulder the entire context of the incident and for that person be the one to suggest lasting corrective actions it leaves little need for the VP to even be involved. How would they know if the proposed corrections are worth the time and money to implement? I don't see any leadership in the example described in the article - I just see a knee-jerk reaction rather than any kind of proactive reflection.

> "I thought we fixed this last time!?"

> "This time was different in a way that our corrective actions didn't address."

Part of the reason Amazon's CoE-driven engineer culture had such operation excellence is that the responsibility was driven the whole way up the management chain. If your manager didn't dig down to the root cause of a sev2, the director was damn well going to, and if the director didn't, Andy Jassy was going to call them on it.

That sounds like a lot of busy work, and a bunch of it undoubtedly is, but the flip side of it is that the actual root causes were addressed, and if the root cause needed serious cross-functional resources to address, the escalation would get you what you needed. Need approval to bounce 3 months of work off your roadmap to address? You have a VP on the line to make that call. Need a couple of other teams to fix their shit? Here's a principal engineer who outranks their directors to drive the work. And so on...

I do think his choice of words was a bit suboptimal. But, it got the point across.

> Instead, ask:

> What are we changing so that the same class of failure is less likely next time?

Why are these framed as being almost mutually exclusive? I don't get it. "How/why did this happen?" informs how you answer "What are we changing?" Even the following section, "Reasonable people", functions in this way with a "Why did this happen?" followed by "What are we changing?".

Just feels like this article has some internal conflict with itself in order to achieve a "don't do that, do this" type of style.

You always add rules, and alerts, and so on. You need to revisit existing processes to and see what can be removed or replaced.

My other nit with these is a term that's abused a lot "Root Cause", most complex issues have many contributing factors, not a single root cause, and if you force the teams to find one, they will.

I dislike RCA (Root Cause Analysis) it puts you in the wrong mindset, CFA would be better (Contributing Factor Analysis).

It boils down to what exactly is the ownership or accountability of your SVP around the issue. Why are they even bothered to ensure that there will be some change? If they are responsible for ensuring that the issue doesn't happen again, then they do need to say "I want the details".

Oops, now I'm fired.

The issue is when the calls and urgency are raised before making some mental space to even verify that there is enough clarity on what happen and these interrupt the clarification and remediation planning process.

Saying you shouldn't ask "Why did this happen?" and you should ask "What we're changing?" instead is wanting to jump the gun and pretend a required step doesn't exist.

It does exists, is just the executive anxiety reasonable in terms of wanting to be protective of the business but as protective as a family member of a patient wanting a good outcome from the surgeon during the surgery.

Only worst because the surgeon's boss is this anxious family member, and she has a laboral gun pointing to the doctor's neck.

In order to figure out a good solution, you have to have mastery over the problem. That takes a bunch of work.

> Understanding an issue is not the same as fixing it. A good explanation can make things worse. Once everyone agrees that the behaviour was reasonable, the urgency to change anything disappears.

This is a non-sequitor. We're not here to evaluate whether the behavior was reasonable, we're here to figure out how to avoid bad outcomes. If all the behavior was reasonable, then the problem lies somewhere else, and that's an important finding when crafting a proper solution.

The author is literally saying that asking why is the wrong question, and instead asking "What will we change?" is the right question. I get where this comes from, but you can't really answer what will change until you deeply understand why it happened.

But also the post reads like it comes from an inexperienced/immature service org, so maybe they’re just sorting their operational response process out.

> Everyone nods their head, says "that makes sense", and we all move on with our day.

Why? Why do you need to be intimidated into actually making effective change? Why is everyone walking around with their hands tied, unable or afraid to enact change? Probably because of the terrible leadership at this company.

>> "We missed it because Alice was on holiday and Bob thought the Widgets team owned it".

> Okay. How do we make ownership unambiguous when someone is unavailable?

You cannot take this step without details. That Bob-Alice story is the details. You do actually need to know that story before you can take the step of knowing that "unambiguous ownership" would be a worthwhile change to make. What exactly is this SVP doing again?

This entire post could be summarized as "executives are useless" and "do the 5-whys", both of which everyone already knows.

  - what happened
  - impact
  - root causes
  - what will be changed (commitments)

It's fine for executives to get only a summary of impact + commitments. But the whole post-mortem process has to be followed, and some people have to be aware of all the details.

People need to tell their stories. They need to be heard and have their work and its difficulty respected.

That's what went wrong. Everything else is an abuse victim rationalizing their abuse.

1. timeline of events

2. impact

3. 5 whys — the details of how and why things happend

4. actionable items

I've never seen a post-mortem without actionable items.

It is understandably a completely different task compared to what those skilled people are specialised to do. You probably need a dedicated role to do it.

Perhaps you could call them a manager. Their job is to see the multiple parts of the system. They should ask for the Details of what happened so they can determine why the problem occurred.

Consider one of the problems listed in the article

>"The alert fired, but the on-call engineer had already dealt with twenty low-value alerts that evening".

The engineer can say they were busy, they didn't see the alert, that they are swamped with things they think are low-value. Someone else can say the alert fired. Each person involved may have their own perspective, with different ideas as to what the problem actually is.

It's easy when you see problem described in terms of what the solution is. Someone needs to figure that out, to do that they need the details.

And maybe this is just a part that the article dodges, but for something described as non-catastrophic, I would suggest that there shouldn't be a presumption of changes. In my view there should be an assessment of the risk of re-occurrence, and if it was a near miss, what is the risk had it not been a near miss. And then even should changes be part of the outcomes, how expensive are those to implement compared to whatever the issue was, and if they're too expensive compared to the risk, don't put resources into it.

I usually do want the details, but I also want to communicate my expectations up top and unambiguously.

I think i’m going to call our ticket support system “folklore” from now on. It sure is used that way.

Everything else is a conversation that takes up space on a post-mortem or runbook.

That line is absolute gold

I like this plan of action, it removes focus from what happened in the past to how can we prevent it from happening in the future.

I'm not saying these moments of discovery / epiphany aren't valuable, they are and this retelling is enjoyably written.

I am saying that action items borne of incidents should be de rigueur.

If you just explain what happened and why, that's fine but...how are you going to make sure it doesn't happen again?

The problem I found more vexing as a manager was: how can you prevent this KIND of problem from occurring?

I'd have someone on my team make a technical error and xyz wouldn't work. Wed talk thru it, and they wouldn't make that exact mistake again. But there's literally 10k things that can go wrong in our system, so then a related mistake would happen later.

What they needed was improved pattern recognition vs if this / then that which comes from post mortems.

Edit: I was wrong. It still reads like LinkedIn to me but “translating” doesn’t help. Thanks in any case.

[1]: https://translate.kagi.com/

When an error occurs we find the root cause but in 99% of cases a change to the environment/process is required to avoid it in the future.

Humans are all imperfect, their competence will change hour to hour let alone day to day. But you can control a system and put checks in place (admittedly a human can still do the process wrong, but then you need to think how the process can be clearer).

No-blame culture is very effective at providing an open environment to share mistakes, learn, but most importantly avoid reoccurance.

A lot of leaders like to hide in the details because the bigger picture is a harder problem.

I appreciate this.

Well that is because it was delivered by someone who was actually being dismissive!

If they want to know what "we are changing" but don't want to know any detail as to why, even presented at an appropriate level, they are very likely looking for you to take all the risk of the decision and they are dismissing your need to have the necessary informed consent for it to become the we.

Now, if you're presenting that information at a level of detail that is truly irrelevant or deep, that is your problem to fix.

But otherwise be very wary of this pattern of communication where "we" might mean "you". Anyone with any sense of risk management should know not to do this.

If you have not seen it, watch Margin Call. When you get to the boardroom scene [0] you'll see this play out, but you will also see the (pretty rapacious, direct) boss understand properly that the information he is getting from a low ranking employee is nevertheless his problem to understand, even if only at a 10,000 feet level.

Beyond the drama of the way the scene ends, it's actually a very good model of how that interaction should play out for everyone — making it clear that everyone in the room shares in the "we" of it, including the decisionmaker.

I have been in rooms where it played out at least something like that, where the boss wants to make an attempt to share the burden of the detail, and I've been able to leave them feeling somewhat supported, or at least without feeling like I was being shafted.

And I've been in rooms with people who don't want to know the details but just want to know what "we" are going to fix — those guys have never been as good to work for. If they say "we" but leave you with the impression they may mean "you", it's bad.

[0] said scene, but really, really, watch the film if you never have:

https://www.americanrhetoric.com/MovieSpeeches/moviespeechma...

>> I know that if we get into the details, the reasons will be perfectly reasonable. You'll explain what happened, I'll understand why everyone made the decisions they made, and I'll empathise with you.

>> Then it'll happen again.

>> So I don't want the details. I want to know what we're changing.

Even if the manager's approach was correct, this is just a hurtful way to frame it to your team. It's great that the author could reverse-engineer what the manager was doing, but it shouldn't come to that.

Why couldn't the manager say something like:

> You are all great engineers, so I already know that everyone made the best decision available with the information they had at the time. What are we going to do differently moving forward?

I'm still not sure I agree with the strategy, because I don't see how you can understand what happens next without understanding what went wrong. But I can see how the framing might help steer the discussion.

...huh? I've been in corporate America for 19 years now and I've never once had this happen. I've never seen anyone just look for the cause and not ask what can be done to prevent it in the future. Everyone KNOWS that question is coming next.

I'm not so sure this means "I trust you."

If you trust someone that much, why are you even in the loop? Why are you badgering them at all? This is just bad management pretending to offer underlings autonomy. As soon as it fails, everyone loses their job.

I couldn't disagree more. "A problem well stated is a problem half solved."

The executive is there to help with the big picture, but you can't see the big picture if the canvas is blank.

If you ask them, of course they will make up a bs story with their fake answer. The fact is that they fail the ablation test.

Neurotypical executive toxic attitudes should be shamed.

Making informed decisions based on assumptions or guesses is always going to result in terrible outcomes.

Apropos, I was once told a Japanese saying: "Fix the problem, not the blame."

I must have repeated this charming story a dozen times before realizing it makes no sense in Japanese -- it relies entirely on English idioms.

He doesn’t want the details, he just wants someone else to tell him what they’re gonna do. But if he doesn’t know the details, he won’t understand if the plan will make things better or worse.

So… what exactly is this presumably valuable person there to do? Just to gage the confidence in the room? Presumably everyone was confident before the mistake happened.

What does this person who just wants a solution add? Why isn’t he fostering a discussion and adding his insight? Why is he in the room at all?

TLDR:

Some outage causes a meeting with an SVP. SVP preempts the discussion with the following:

“I know that if we get into the details, the reasons will be perfectly reasonable. You'll explain what happened, I'll understand why everyone made the decisions they made, and I'll empathise with you.

Then it'll happen again.

So I don't want the details. I want to know what we're changing.”

If our overarching objectives don't impact our on-the-ground decisions, what are you even for?