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Part 4 of 7 · Incident postmortem collector series ~5 min read

What happens to the action items

This is the post that decides whether the whole practice survives, because a process whose outputs visibly go nowhere stops attracting anybody’s effort within about a year.

Key takeaways

  • Most postmortem actions are never done and never closed.
  • Declined is a legitimate end state and is better than open forever.
  • Three actions that get done beat nine that do not.
  • Every action needs an owner who agreed to it, in the room.
  • Publish the open count; it is the health metric for the whole practice.

The graveyard

Postmortem actions completed and left open over three yearsA stacked bar chart with three bars. Two series: actions completed in green, and actions still open in red. Year one: fourteen completed and nine open. Year two: eleven completed and twenty-two open. Year three: eight completed and forty-one open. A note says by year three, participation in postmortems has usually collapsed too.020406080~23Year 1~33Year 2~49Year 3Actions completedActions still openBy year three, participation in postmortems has usually collapsed too.
Fig 1. Three years of postmortem actions in a typical organisation. The growing red column is what people see, and it is what they conclude the process produces.

The causal link between the two is direct. People spend four hours on a review, three actions come out of it, none of them happen, and the next time an incident occurs the review is shorter and less honest because everybody knows what it produces.

Declining is legitimate

How an ageing postmortem action item is resolvedA vertical chain of five steps entered by a box labelled An action, ninety days old and not started. Step one asks the owner, once and plainly. Step two asks whether they are still going to do it, honestly; a yes exits to A new date, and that is fine. Step three asks whether priorities changed, which they usually have; if so it exits to Close as declined, with the reason. Step four asks whether it is still important but nobody has time; if so it exits to Escalate once, for a decision either way. Step five closes it one way or another, with nothing staying open. A note says declining an action is a decision and leaving it open is an absence of one.AWS ACCOUNTAn action, 90 days oldnot startedAsk the owneronce, plainlyStill going to do it?honestlyA new dateand that is fineyesPriorities changed?usuallyClose as declinedwith the reasonyesStill important?but nobody has timeEscalate oncea decision, either wayyesClosed, one way or anothernothing stays openDeclining an action is a decision. Leaving it open is an absence of one.
Fig 2. How an ageing action is resolved. Every path ends in a closed state, which is what keeps the open list meaningful.
  • App integration
  • Machine learning
  • Management
  • People

Why declining is better than open

An action declined with a reason is information: we decided this risk was acceptable, on this date, for this reason. If the incident recurs, that decision is on the record and can be revisited with evidence.

The same action left open for three years contains no decision, no information, and no protection. It is worse in every respect except that nobody had to say no.

How many actions

How many postmortem actions get completed at three different list lengthsA stacked bar chart with three bars. Two series: completed within ninety days in green, and not completed in grey. Nine actions: two completed and seven not. Five actions: three completed and two not. Three actions: three completed and none outstanding. A note says three actions produce more change than nine, which is consistent and unintuitive.05101520~99 actions~55 actions~33 actionsCompleted within 90 daysNot completedThree actions produce more change than nine. This is consistent and unintuitive.
Fig 3. Completion rates against the number of actions per postmortem. Fewer actions produce more completed work, not less.

The mechanism is straightforward: a list of nine has no ordering that anybody believes, so none of them is the next thing to do. A list of three is a list somebody can hold and act on.

The discipline is at the end of the review: of these eight things we could do, which three actually matter? The other five are written into the document as considered and not chosen, which preserves the thinking without creating an obligation.

An owner who agreed

An action assigned to somebody who was not in the room is an action that will not happen, and assigning work to a team rather than a person is the same thing with extra steps.

The owner should be present, should say yes, and should give a date they believe. A date chosen to end the meeting is worse than no date because it produces a false sense of commitment that expires quietly.

The health metric

The single number worth publishing is the count of actions open beyond their date. Not how many postmortems were written, not how many incidents there were, and not the completion percentage, which can be gamed by writing fewer actions.

An open-and-overdue count that stays under about five is a practice that works. One that grows every quarter is telling you, well in advance, that the postmortem process is about to stop being taken seriously.

Next: reading them again.

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