Chapter 4

Does finding who's to blame make systems safer?

Tìm ra người có lỗi có làm hệ thống an toàn hơn?

The chapter's question

After an incident, what did my team learn and what did we fix in the system?

Big idea

Ask who caused the error and people hide; ask why the system let it through and people talk.

In this chapter

  1. Part 4.1

    The Timeline

    What happened, minute by minute?

  2. Part 4.2

    Asking Why Five Times

    How many layers deeper than the direct cause does the root cause lie?

  3. Part 4.3

    Action Items With Owners

    Does every fix have a person's name and a completion date?

  4. Part 4.4

    Sharing the Lesson

    Can other teams read this review?

The reading for this chapter is inside Conan School

This chapter has 4 readings, with case stories and exercises. Chapter 1 of The Two A.M. Incident is free to read right here.

Read in Conan School

Chapters of The Two A.M. Incident

  1. 1.Why do customers find our outages before we do?
  2. 2.Mid-outage, should we hunt for the cause first?
  3. 3.Can you trust your own judgment at 2 a.m.?
  4. 4.Does finding who's to blame make systems safer?
  5. 5.Is this a new incident, or an unpaid old one?