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Postmortem Writing

Seth HobsonCommunityCreated by Seth Hobson

  • Skill
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  • Software development
  • MIT
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From the author

Write effective blameless postmortems with root cause analysis, timelines, and action items. Use when conducting incident reviews, writing postmortem documents, or improving incident response processes.
— the description by Seth Hobson

AutoGineer summary

Written by AutoGineer from the skill’s own files, not by the author

This skill provides a structured approach to incident reviews, emphasizing a blameless culture where the focus remains on systemic improvements rather than individual fault. It includes templates for standard and quick postmortems, a 5 Whys analysis framework, and a facilitation guide for running effective review meetings. By standardizing how teams document timelines, root causes, and action items, it helps organizations transform technical failures into actionable learning opportunities.

What it does

  • Provides templates for standard and quick postmortem documentation
  • Offers a 5 Whys analysis framework to identify root causes
  • Outlines a 60-minute meeting structure for incident reviews
  • Defines best practices for maintaining a blameless culture
  • Lists anti-patterns to avoid during incident analysis
  • Suggests a timeline for incident follow-up and resolution

When to use it

  • After SEV1 or SEV2 incidents
  • Following customer-facing outages or data loss
  • When analyzing near-misses that could have been severe
  • During routine incident review meetings
  • When improving internal incident response processes

Advantages

  • Promotes psychological safety by removing blame
  • Ensures consistent documentation across different teams
  • Focuses on systemic fixes rather than temporary patches
  • Helps identify recurring patterns in incident data
  • Provides clear, actionable steps for incident resolution

Usage examples

“Help me draft a postmortem for a recent database outage.”
The agent will provide a structured template and guide you through documenting the timeline, root cause, and systemic improvements.
“How do I facilitate a blameless postmortem meeting?”
The agent will outline a 60-minute meeting agenda, including tips for keeping the discussion focused on systems rather than individuals.
“Perform a 5 Whys analysis for a service failure.”
The agent will walk you through five levels of questioning to uncover the underlying systemic causes of the failure.

Install

  1. Download the skill as a ZIP:

    https://autogineer.com/agent-skills/wshobson/postmortem-writing/download
  2. Unzip it into the cross-client skills folder of your project:

    mkdir -p .agents/skills && unzip postmortem-writing.zip -d .agents/skills

Documentation by Seth Hobson

Postmortem Writing

Comprehensive guide to writing effective, blameless postmortems that drive organizational learning and prevent incident recurrence.

When to Use This Skill

  • Conducting post-incident reviews

  • Writing postmortem documents

  • Facilitating blameless postmortem meetings

  • Identifying root causes and contributing factors

  • Creating actionable follow-up items

  • Building organizational learning culture

Core Concepts

1. Blameless Culture
Blame-FocusedBlameless
"Who caused this?""What conditions allowed this?"
"Someone made a mistake""The system allowed this mistake"
Punish individualsImprove systems
Hide informationShare learnings
Fear of speaking upPsychological safety
2. Postmortem Triggers
  • SEV1 or SEV2 incidents

  • Customer-facing outages > 15 minutes

  • Data loss or security incidents

  • Near-misses that could have been severe

  • Novel failure modes

  • Incidents requiring unusual intervention

Quick Start

Postmortem Timeline
Day 0: Incident occurs
Day 1-2: Draft postmortem document
Day 3-5: Postmortem meeting
Day 5-7: Finalize document, create tickets
Week 2+: Action item completion
Quarterly: Review patterns across incidents

Templates and detailed worked examples

Full template library and detailed worked examples live in references/details.md. Read that file when you need the concrete templates.

Template 2: 5 Whys Analysis
# 5 Whys Analysis: [Incident]

## Problem Statement

Payment service experienced 47-minute outage due to database connection exhaustion.

## Analysis

### Why #1: Why did the service fail?

**Answer**: Database connections were exhausted, causing all new requests to fail.

**Evidence**: Metrics showed connection count at 100/100 (max), with 500+ pending requests.

---

### Why #2: Why were database connections exhausted?

**Answer**: Each incoming request opened a new database connection instead of using the connection pool.

**Evidence**: Code diff shows direct `DriverManager.getConnection()` instead of pooled `DataSource`.

---

### Why #3: Why did the code bypass the connection pool?

**Answer**: A developer refactored the repository class and inadvertently changed the connection acquisition method.

**Evidence**: PR #1234 shows the change, made while fixing a different bug.

---

### Why #4: Why wasn't this caught in code review?

**Answer**: The reviewer focused on the functional change (the bug fix) and didn't notice the infrastructure change.

**Evidence**: Review comments only discuss business logic.

---

### Why #5: Why isn't there a safety net for this type of change?

**Answer**: We lack automated tests that verify connection pool behavior and lack documentation about our connection patterns.

**Evidence**: Test suite has no tests for connection handling; wiki has no article on database connections.

## Root Causes Identified

1. **Primary**: Missing automated tests for infrastructure behavior
2. **Secondary**: Insufficient documentation of architectural patterns
3. **Tertiary**: Code review checklist doesn't include infrastructure considerations

## Systemic Improvements

| Root Cause    | Improvement                       | Type       |
| ------------- | --------------------------------- | ---------- |
| Missing tests | Add infrastructure behavior tests | Prevention |
| Missing docs  | Document connection patterns      | Prevention |
| Review gaps   | Update review checklist           | Detection  |
| No canary     | Implement canary deployments      | Mitigation |
Template 3: Quick Postmortem (Minor Incidents)
# Quick Postmortem: [Brief Title]

**Date**: 2024-01-15 | **Duration**: 12 min | **Severity**: SEV3

## What Happened

API latency spiked to 5s due to cache miss storm after cache flush.

## Timeline

- 10:00 - Cache flush initiated for config update
- 10:02 - Latency alerts fire
- 10:05 - Identified as cache miss storm
- 10:08 - Enabled cache warming
- 10:12 - Latency normalized

## Root Cause

Full cache flush for minor config update caused thundering herd.

## Fix

- Immediate: Enabled cache warming
- Long-term: Implement partial cache invalidation (ENG-999)

## Lessons

Don't full-flush cache in production; use targeted invalidation.

Facilitation Guide

Running a Postmortem Meeting
## Meeting Structure (60 minutes)

### 1. Opening (5 min)

- Remind everyone of blameless culture
- "We're here to learn, not to blame"
- Review meeting norms

### 2. Timeline Review (15 min)

- Walk through events chronologically
- Ask clarifying questions
- Identify gaps in timeline

### 3. Analysis Discussion (20 min)

- What failed?
- Why did it fail?
- What conditions allowed this?
- What would have prevented it?

### 4. Action Items (15 min)

- Brainstorm improvements
- Prioritize by impact and effort
- Assign owners and due dates

### 5. Closing (5 min)

- Summarize key learnings
- Confirm action item owners
- Schedule follow-up if needed

## Facilitation Tips

- Keep discussion on track
- Redirect blame to systems
- Encourage quiet participants
- Document dissenting views
- Time-box tangents

Anti-Patterns to Avoid

Anti-PatternProblemBetter Approach
Blame gameShuts down learningFocus on systems
Shallow analysisDoesn't prevent recurrenceAsk "why" 5 times
No action itemsWaste of timeAlways have concrete next steps
Unrealistic actionsNever completedScope to achievable tasks
No follow-upActions forgottenTrack in ticketing system

Best Practices

Do's
  • Start immediately - Memory fades fast

  • Be specific - Exact times, exact errors

  • Include graphs - Visual evidence

  • Assign owners - No orphan action items

  • Share widely - Organizational learning

Don'ts
  • Don't name and shame - Ever

  • Don't skip small incidents - They reveal patterns

  • Don't make it a blame doc - That kills learning

  • Don't create busywork - Actions should be meaningful

  • Don't skip follow-up - Verify actions completed

Files

references/details.md

postmortem-writing — templates and worked examples

Templates

Template 1: Standard Postmortem
# Postmortem: [Incident Title]

**Date**: 2024-01-15
**Authors**: @alice, @bob
**Status**: Draft | In Review | Final
**Incident Severity**: SEV2
**Incident Duration**: 47 minutes

## Executive Summary

On January 15, 2024, the payment processing service experienced a 47-minute outage affecting approximately 12,000 customers. The root cause was a database connection pool exhaustion triggered by a configuration change in deployment v2.3.4. The incident was resolved by rolling back to v2.3.3 and increasing connection pool limits.

**Impact**:

- 12,000 customers unable to complete purchases
- Estimated revenue loss: $45,000
- 847 support tickets created
- No data loss or security implications

## Timeline (All times UTC)

| Time  | Event                                           |
| ----- | ----------------------------------------------- |
| 14:23 | Deployment v2.3.4 completed to production       |
| 14:31 | First alert: `payment_error_rate > 5%`          |
| 14:33 | On-call engineer @alice acknowledges alert      |
| 14:35 | Initial investigation begins, error rate at 23% |
| 14:41 | Incident declared SEV2, @bob joins              |
| 14:45 | Database connection exhaustion identified       |
| 14:52 | Decision to rollback deployment                 |
| 14:58 | Rollback to v2.3.3 initiated                    |
| 15:10 | Rollback complete, error rate dropping          |
| 15:18 | Service fully recovered, incident resolved      |

## Root Cause Analysis

### What Happened

The v2.3.4 deployment included a change to the database query pattern that inadvertently removed connection pooling for a frequently-called endpoint. Each request opened a new database connection instead of reusing pooled connections.

### Why It Happened

1. **Proximate Cause**: Code change in `PaymentRepository.java` replaced pooled `DataSource` with direct `DriverManager.getConnection()` calls.

2. **Contributing Factors**:
   - Code review did not catch the connection handling change
   - No integration tests specifically for connection pool behavior
   - Staging environment has lower traffic, masking the issue
   - Database connection metrics alert threshold was too high (90%)

3. **5 Whys Analysis**:
   - Why did the service fail? → Database connections exhausted
   - Why were connections exhausted? → Each request opened new connection
   - Why did each request open new connection? → Code bypassed connection pool
   - Why did code bypass connection pool? → Developer unfamiliar with codebase patterns
   - Why was developer unfamiliar? → No documentation on connection management patterns

### System Diagram

[Client] → [Load Balancer] → [Payment Service] → [Database] ↓ Connection Pool (broken) ↓ Direct connections (cause)


## Detection

### What Worked
- Error rate alert fired within 8 minutes of deployment
- Grafana dashboard clearly showed connection spike
- On-call response was swift (2 minute acknowledgment)

### What Didn't Work
- Database connection metric alert threshold too high
- No deployment-correlated alerting
- Canary deployment would have caught this earlier

### Detection Gap
The deployment completed at 14:23, but the first alert didn't fire until 14:31 (8 minutes). A deployment-aware alert could have detected the issue faster.

## Response

### What Worked
- On-call engineer quickly identified database as the issue
- Rollback decision was made decisively
- Clear communication in incident channel

### What Could Be Improved
- Took 10 minutes to correlate issue with recent deployment
- Had to manually check deployment history
- Rollback took 12 minutes (could be faster)

## Impact

### Customer Impact
- 12,000 unique customers affected
- Average impact duration: 35 minutes
- 847 support tickets (~7% of affected users)
- Customer satisfaction score dropped 12 points

### Business Impact
- Estimated revenue loss: $45,000
- Support cost: ~$2,500 (agent time)
- Engineering time: ~8 person-hours

### Technical Impact
- Database primary experienced elevated load
- Some replica lag during incident
- No permanent damage to systems

## Lessons Learned

### What Went Well
1. Alerting detected the issue before customer reports
2. Team collaborated effectively under pressure
3. Rollback procedure worked smoothly
4. Communication was clear and timely

### What Went Wrong
1. Code review missed critical change
2. Test coverage gap for connection pooling
3. Staging environment doesn't reflect production traffic
4. Alert thresholds were not tuned properly

### Where We Got Lucky
1. Incident occurred during business hours with full team available
2. Database handled the load without failing completely
3. No other incidents occurred simultaneously

## Action Items

| Priority | Action | Owner | Due Date | Ticket |
|----------|--------|-------|----------|--------|
| P0 | Add integration test for connection pool behavior | @alice | 2024-01-22 | ENG-1234 |
| P0 | Lower database connection alert threshold to 70% | @bob | 2024-01-17 | OPS-567 |
| P1 | Document connection management patterns | @alice | 2024-01-29 | DOC-89 |
| P1 | Implement deployment-correlated alerting | @bob | 2024-02-05 | OPS-568 |
| P2 | Evaluate canary deployment strategy | @charlie | 2024-02-15 | ENG-1235 |
| P2 | Load test staging with production-like traffic | @dave | 2024-02-28 | QA-123 |

## Appendix

### Supporting Data

#### Error Rate Graph
[Link to Grafana dashboard snapshot]

#### Database Connection Graph
[Link to metrics]

### Related Incidents
- 2023-11-02: Similar connection issue in User Service (POSTMORTEM-42)

## References
- [Connection Pool Best Practices](internal-wiki/connection-pools)
- [Deployment Runbook](internal-wiki/deployment-runbook)

Requirements and compatibility

Works with: Claude Code, Claude apps, OpenAI Codex, GitHub Copilot, Cursor, Gemini CLI, Kiro, OpenCode, Goose, Amp, Roo Code, JetBrains Junie, Factory Droid, Devin (ex-Windsurf), Mistral Vibe, OpenHands, Letta

“Works with” means the tool reads the open Agent Skills format; a skill written for one tool may use features others lack.

Security

No issues found by our static scan· No issues found

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Attribution and licence

Created by
Seth Hobson
Publisher
Seth Hobson (Community)
Source
wshobson/agents · plugins/incident-response/skills/postmortem-writing · commit 4bde316
Licence
MIT License (redistribution allowed)
  • LICENSE (added by AutoGineer from LICENSE)
  • ATTRIBUTION.md (written by AutoGineer)
Synced

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Download ZIP

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