Post-Incident Review: Addressing Systemic Issues

Crisis Leadership & Incident ResponseMid10–15 min

Introduction: What You’ll Learn

This simulation will walk you through running a post-incident review focused on uncovering and addressing systemic issues. You'll learn how to facilitate a discussion that identifies root causes and develops practical solutions to prevent future incidents.

You’ll practice:

  • Structuring the review meeting to encourage participation
  • Facilitating open, constructive communication
  • Identifying systemic issues and root causes collaboratively
  • Developing actionable solutions with team consensus

Step-by-Step Simulation

Scene 1: Setting the Stage

Facilitator: "Hey everyone, thanks for joining today’s post-incident review. Our main goal is to figure out what led to the incident and find ways to prevent it from happening again. Let’s start with a quick recap of what went down."

Facilitator (as an observer): "Last Friday, we had an outage that took down our user authentication service for three hours. It looks like the root cause was a misconfigured load balancer that triggered a chain reaction."


Scene 2: Gathering Perspectives

Facilitator: "I’d love to hear your thoughts on what happened during the incident and any systemic issues you think might be involved. Leo, how about we start with you?"

Leo: "Our alerting system didn’t catch the issue early on. By the time we realized something was wrong, things were already pretty bad. We definitely need to improve our monitoring."

Facilitator: "Thanks, Leo. That’s a big one. Priya, what did you notice?"

Priya: "I was on-call and found the incident response playbook a bit confusing for this type of scenario. It took extra time to coordinate with the team."

Facilitator: "Good feedback. Alex, what’s your take?"

Alex: "The configuration changes were rolled out without a peer review. We need stricter deployment protocols."

Facilitator: "Got it. Deployment protocols are definitely on our list. Sara, any observations from your side?"

Sara: "I helped with the recovery, and we hit delays due to environment inconsistencies. Our staging setup isn’t quite like production."

Facilitator: "Thanks, Sara. It sounds like we have a few key areas to dig into."


Scene 3: Identifying Root Causes

Facilitator: "Let’s dive deeper and identify some root causes. We’ve got monitoring gaps, unclear playbooks, deployment protocols, and environment inconsistencies. Which of these seem systemic to you?"

Leo: "Monitoring gaps feel systemic. It’s not the first time we’ve had this issue."

Facilitator: "Agreed. Alex, what do you think about the deployment process?"

Alex: "Definitely systemic. We need better checks to prevent unauthorized changes."

Facilitator: "Good call. Priya, anything else on the playbook clarity?"

Priya: "It might be a one-off, but keeping it updated should be a priority."

Facilitator: "Absolutely. Consistent updates are key. Sara, what about environment parity?"

Sara: "That’s systemic too. We’ve had similar issues before."

Facilitator: "Alright, let’s focus on monitoring, deployment protocols, and environment parity for our next steps."


Scene 4: Developing Actionable Solutions

Facilitator: "Now, let’s brainstorm some solutions. What can we do to tackle these issues?"

Sara: "How about we set up automated alerts for key metrics and regularly audit our monitoring gaps?"

Facilitator: "Sounds great. Alex?"

Alex: "Introduce mandatory peer reviews for all configuration changes."

Facilitator: "Solid plan. Priya, any ideas for the playbook?"

Priya: "Let’s do quarterly reviews and have team drills to ensure clarity."

Facilitator: "Great approach. And for environment parity, Sara?"

Sara: "We should allocate resources to align staging and production environments better."

Facilitator: "Let’s figure out who can take the lead on each of these actions."

(Leo will lead monitoring improvements, Alex on deployment protocols, Priya on playbook updates, and Sara on environment parity.)


Scene 5: Wrapping Up

Facilitator: "To sum up, we’ll improve monitoring with automated alerts and audits, enforce peer reviews for deployments, keep our playbooks updated, and align staging with production. I’ll check in with you all to track progress and help where needed."

Facilitator: "Thanks for your input today. Let’s meet again in a few weeks to see how we’re doing and make any tweaks necessary. Keep the lines of communication open, and let’s support each other."


Mini Roleplay Challenges

Challenge 1: Someone suggests, “We need more people on-call.”

  • Best Response: “That’s a valid point. Let’s see how we can optimize on-call rotations without overloading the team.”

Challenge 2: A team member is defensive about the deployment process.

  • Best Response: “We’re here to learn and improve, not to point fingers. Let’s work on strengthening the process together.”

Challenge 3: Disagreement arises over the root cause.

  • Best Response: “Let’s agree to gather more data or examples to clarify this point. Can someone take that on?”

Optional Curveball Mode

  • A key team member is absent.
  • New information about the incident comes up mid-discussion.
  • Time is running short, but key issues are unresolved.

Reflection Checklist

Facilitation

  • Did I keep the meeting constructive and focused?
  • Did I ensure all voices were heard?

Outcomes

  • Did we identify systemic issues?
  • Did we agree on actionable solutions?

Team Growth

  • Did we foster a culture of learning and improvement?
  • Did the team feel empowered to implement changes?

Common Mistakes to Avoid

  • Getting stuck on symptoms instead of root causes
  • Allowing blame to overshadow productive discussion
  • Leaving without a clear action plan and ownership