Post Mortem

Post-Mortem

Conduct a post-mortem for "$ARGUMENTS". Define the incident or event, build a timeline, perform root cause analysis using the 5 Whys technique, and produce corrective actions at multiple levels with owners and review dates.

Prerequisites

Check that .project/$ARGUMENTS/00-initiate.md exists. If it does not, tell the user to run an Initiate skill first (e.g., project-charter) and stop.

If the user passes --skip-checks, skip the prerequisite check and log the skip to .project/$ARGUMENTS/skip-log.md with a timestamp and reason.

Process

1. Read existing context:

   • Read .project/$ARGUMENTS/00-initiate.md for project context, team setup, and stakeholder information
   • Read .project/$ARGUMENTS/03-review.md if it exists (for sprint metrics and delivery data around the incident period)
   • Read .project/$ARGUMENTS/04-improve.md if it exists (for previous post-mortems, retrospective themes, and known risks)
   • Read .project/$ARGUMENTS/02-sprint.md if it exists (for standup history and blocker log around the incident period)

2. Define the incident or event:

   • Ask the user to describe what happened — get the facts before analysis
   • Document clearly:
     • What happened — objective description of the incident or event
     • When it happened — start time, detection time, resolution time, total duration
     • Who was affected — users, customers, internal teams, stakeholders
     • Impact — quantify where possible (users affected, revenue lost, data compromised, SLA breached)
     • Severity — classify as critical (service down), major (significant degradation), minor (limited impact), or informational (near-miss)
   • Distinguish between the symptoms (what was observed) and the incident itself (what actually went wrong)

3. Build timeline of events:

   • Reconstruct the incident chronologically from earliest relevant event to resolution
   • For each event in the timeline, document:
     • Timestamp — when it happened (as precise as possible)
     • What happened — factual description of the event
     • Who was involved — which person or system took action or was affected
     • Impact at this point — how the situation changed
   • Key milestones to capture:
     • When the conditions for the incident were first introduced (the seed)
     • When the incident actually began (the trigger)
     • When the incident was first detected (by monitoring, users, or team)
     • When the first responder engaged
     • What diagnostic steps were taken and in what order
     • When the root cause was identified
     • When the fix was applied
     • When service was fully restored
     • When the incident was formally closed
   • Note any gaps in the timeline — periods where it is unclear what happened or why

4. Identify root causes using 5 Whys:

   • Start with the incident statement and ask "Why did this happen?"
   • For each answer, ask "Why?" again until reaching a systemic cause (typically 3-5 levels deep)
   • Continue until the answer points to a process, system, or organizational issue — not a person's mistake
   • Document each level of the 5 Whys chain clearly:
     • Why 1: [symptom-level cause]
     • Why 2: [deeper cause]
     • Why 3: [process or system gap]
     • Why 4: [organizational or structural cause]
     • Why 5: [root cause — the systemic issue]
   • If there are multiple causal chains (multiple contributing factors), run 5 Whys on each
   • Stop when the answer is something the team or organization can actually change

5. Distinguish contributing factors from root causes:

   • List all factors that contributed to the incident
   • Classify each as:
     • Root cause — the primary systemic issue that, if fixed, would have prevented the incident
     • Contributing factor — made the incident worse or more likely, but was not the primary cause
     • Mitigating factor — reduced the impact or duration of the incident
   • There is usually 1-2 root causes and several contributing factors
   • Common contributing factors: missing monitoring, unclear runbooks, single points of failure, inadequate testing, communication gaps

6. Define corrective actions at 3 levels:

   • Immediate actions (fix the symptom):
     • What was done to resolve this specific incident
     • Any temporary measures in place (workarounds, manual processes, increased monitoring)
     • Timeline for removing temporary measures
   • Short-term actions (prevent recurrence):
     • Specific changes to prevent this exact incident from happening again
     • Examples: add monitoring alert, write a test for the failure case, update the runbook, fix the specific bug
     • Target completion: within 1-2 sprints
   • Long-term actions (fix the system):
     • Structural changes to prevent this class of incidents
     • Examples: improve deployment pipeline, add chaos testing, redesign the architecture for resilience, establish review processes
     • Target completion: within 1-2 quarters
   • Each action item must have an owner and a deadline

7. Identify what went well:

   • Not everything in an incident is negative — capture the positives
   • Examples of things that went well:
     • Fast detection (monitoring worked as intended)
     • Quick response (on-call engineer engaged promptly)
     • Effective communication (stakeholders were informed, team coordinated well)
     • Graceful degradation (system failed partially rather than completely)
     • Good documentation (runbooks were helpful, previous post-mortems informed the response)
   • Recognizing what went well builds team confidence and reinforces good practices

8. Write blameless summary:

   • Write a concise summary of the incident and its resolution
   • Focus on systems and processes, not individual people's mistakes
   • Use language like "the process did not catch" rather than "person X failed to"
   • Frame findings as opportunities to strengthen the system, not as failures
   • Acknowledge that the people involved made reasonable decisions given the information they had at the time
   • If human error was involved, ask what about the system made that error possible or likely

9. Assign action item owners and review dates:

   • For each corrective action, assign a single owner (not a team — one person accountable)
   • Set a specific review date for each action (when to check if it has been completed)
   • Schedule a follow-up review meeting (typically 2-4 weeks after the post-mortem) to verify:
     • Immediate actions are complete
     • Short-term actions are in progress
     • Long-term actions are planned and resourced
   • Add action items to the team's backlog or issue tracker

10. Write the artifact — append to .project/$ARGUMENTS/04-improve.md under a ## Post-Mortem: [Incident/Event] section:

    • Incident Summary — blameless description of what happened, when, and impact
    • Severity — classification with justification
    • Timeline — chronological reconstruction of events
    • Root Cause Analysis — 5 Whys chain(s) with root cause identification
    • Contributing Factors — factors that made the incident worse or more likely
    • What Went Well — positive aspects of detection, response, and resolution
    • Corrective Actions — immediate, short-term, and long-term actions with owners and deadlines
    • Follow-Up Review — date and agenda for the review meeting

Output

Post-mortem appended to .project/$ARGUMENTS/04-improve.md. Present a summary highlighting:

• Incident summary with severity and duration
• Root cause (one sentence)
• Number of corrective actions by level (immediate, short-term, long-term)
• What went well (top 1-2 positives)
• Follow-up review date