Why the Postmortem Doesn’t Work

The Kansas City Star recently published a harrowing and eye-opening report on firefighter deaths.

“When fire departments fail to learn from each other’s mistakes, firefighters pay the price. Hundreds have been killed and tens of thousands injured over the last two decades, in incidents that mirrored one another. The rate of on-duty firefighter deaths and injuries is nearly as high as it was 40 years ago. In 201 fatalities analyzed by The Kansas City Star 157 firefighters died in unoccupied buildings. In The Star’s analysis, only 11 died while trying to rescue civilians trapped in a burning structure.”

Firefighters are taught a simple mantra: Risk a lot to save a lot, risk a little to save a little and risk nothing to save nothing. It turns out that fire departments have different interpretations of risk — and how to protect their workers from danger — because there are no federal safety guidelines.

What’s more unfortunate is that there isn’t an industrywide culture of collaboration. Sure, there are training courses. But when a unit suffers a fatality, the accident is viewed as a local incident. The postmortem documentation, written by an investigatory body to help everybody understand what went horribly wrong, isn’t shared in a national registry.

In fact, firefighters who have written postmortem reports have gone into the field after those reports have been filed and witnessed firefighters making the very same, and sometimes fatal, mistakes over and over again.

What’s glaringly clear to us at GlitchPath is that postmortems don’t work. Even with significant insights and actionable takeaways, postmortem analysis of anything — a lost client, a failed recruiting project — is often too little, too late.

If you can get your team to rally around a postmortem, that’s great. But seasoned leaders find that enthusiasm peaks at the beginning of a project and is almost nonexistent at the end. So if you want the most out of your people, especially new team members with fresh perspectives, you start with a positive attitude and challenge them to make changes at the beginning of a project.

GlitchPath believes that the best people to solve problems are the ones closest to the issues. That’s why we encourage teams to start with a premortem where they envision failure — gently, jokingly, but with earnestness — and plan to avoid major pitfalls by offering solutions before the project begins.

To be fair, we also believe in the merits of a postmortem. But the postmortem should be used to validate the premortem exercise. We encourage questions, such as:

  • What did we get right?
  • What did we get wrong?
  • What assumptions were flawed?
  • How can we help future teams see their blind spots faster?

A postmortem is a valuable tool, but as you read from the reporting in The Kansas City Star, it fails to prevent firefighters from dying in preventable ways.

So try something new on your team, today. Begin to implement the concept of the premortem, and please let us know how it works.

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