Ask how it made sense at the time.
Blame shrinks the information you get. Blameless reviews, popularised in tech by John Allspaw at Etsy, fix the system instead. The delivery process lives in the Agile & Delivery pillar.
Timeline
What Happened
- Facts in sequence
- Actions, not accusations
- Include what went right
Factors
Why It Made Sense
- What did they know then?
- What did the system allow?
- No “human error” as root cause
Actions
Change The System
- Guardrails, not warnings
- Owned and dated
- Shared widely
Source: Etsy Code as Craft ↗
Fix the system that let it happen.