This is my reading notes from the Debriefing Facilitation Guide book.
Introduction
Traditional incident investigation tries to find someone to blame. That doesn’t result in an improved and safer future. We should instead focus on improvement and learning.
People do what makes sense to them at the time, given the context, their experience and skills. We should discover how people perceived their world at the time of the incident. Have people tell stories. Ask open-ended questions.
The debriefing
Each actor in an incident will have different context on what happened. A facilitator’s goal is to ask questions that shed light on the contrasting and complementary parts of the story. Because everyone is an expert, we see during debriefings where expertise lies, and what makes people’s work difficult.
We all learn from experience. In our case, by having done lots of incidents. We need to make the incidents debriefings available and searchable so everyone in the company can learn from them.
The goal of debriefings is to have the company learn. Not to produce remediations items. Adding a graph to an already full dashboard will only cause more noise.
The debrief facilitator shoul be someone who wasn’t involved in the event. Not even in its periphery.
There are still a few elements necessary for structuring and preparing a debriefing.
Familiarize with the timeline in advance
Before the debriefing, get an objective idea of the flow of events, without forming an opinion. The people closest to the event should create the initial timeline. It will let you get a broader idea of what happened to better structure the meeting.
Unearth more objective and subjective data
When someone says “X happened”, ask questions that provide context for X. Make sure everyone involved in the incident are present and can provide their own context. Those people might be blaming themselves for the incident. A facilitator’s job is to make sure they feel safe telling their story.
Talk to the people who would usually be blamed
Establish a sense of trust with all participants. Feeling anxious or embarassed is what makes them the best teachers for their coworkers.
Come up with initial questions
What seems like important pivot points in the timeline? Prepare only open-ended questions. Ones which aren’t answered by yes/no.
Documentation
Appoint someone for taking notes. Pick any tool that fits, as long as the notes are searchable.
Setting expectations
Make sure everyone understands the goal of the meeting. We are not coming together to prevent a future event from happening. We’re joining to learn.
Structure of the discussion
Stick closely to the timeline. At least 2/3 of the meeting should be on that. Do not discuss remediation items right now. Often, those items become moot by the time we’ve finished unfolding the timeline. Make sure everybody agrees it’s comprehensive and accurate.
Then, have everyone brainstorm on what they learned during that incident. They have to say everything that comes to mind, and not censor themselves.
Finally, create remediation items that are specific, measurable and achievable. But keep other ideas as a brainstorming list. Choose a small set of people close to the incident and ask them to think about those items.
A couple days later, bring those people back together to discuss those items again. Insight generally appears when we aren’t forcing it.
Having remediation items is not a requirement though. What we learn is the most important.
The art of asking questions
As a facilitator, the only thing to keep in mind is to discover the story behind the story. The questions are much more important than the answers.
Model a dynamic where mutual understanding is ensured every step of the way. Some people can feel incomfortable with that. The questions asked should make sure people are feeling safe to answer them.
Look for descriptions, not explanations. Don’t ask “why”. Ask “how”. Questions should reveal:
- Cues that lead people to make observations
- Context for things assessed or judgments
- Rationales for choices or decisions
- Things people know, and might assume everyone else knows
- People’s states of mind at the time
- Mental models for how things should work
- Factors which led people to a specific action
- Signals which bring people to ask for help
Example: someone says “So I decided to page the oncall”. Questions:
- What brought you to that decision?
- Have you ever done it in the past?
- Have you ever not done it under similar circumstances?
Invisible parts of expertise
Things done during an incident will not always be apparent to other people, or even the ones who did them. Expertise is tacit knowledge. A facilitator’s role is to make those things visible. Do that by targetting assumptions, expectations, judgments with questions.
- What do they typically see?
- How do they see distinctions?
- How do they see the future unfolding?
When in doubt, or lost, ask dumb questions. It will put people in a position of showcasing their expertise. It also makes sure everyone is on the same page.
The goal is to get people to understand the incident from a different perspective.
When to go deeper
The facilitator needs to decide when to zoom in or out. If someone says things like “obviously”, it’s a sign we need to clarify what makes that obvious. Zooming out is asking about connections between perspectives, to bring the conversation back into the crucial points. Knowing when to zoom in or out is hard, but gets better with practice.
Is it a success?
Two success metrics:
- The acquisition of new information which affects future work.
Did at least one person learn one thing which will affect their future work? - The willigness to participate in future meetings.
Did at least 50% of the attendees say they will attend another debrief in the future?
For debriefs to be useful, people must feel safe. Not just in the room, but in the community. They shall not fear retribution or punishment, or they won’t share their point of view.
Always be aware of what’s happening in the room (confused looks, eyes rolling), and rely on that.
Conclusion
Do we want to judge people’s actions, or do we want to truly learn what happened?