This is part of the Post-Mortem series. Read the Executive Brief (7 min), the Field Guide (20 min), or the Definitive Guide (60 min, canonical).
The Recurring Nightmare
A director explained the same database timeout issue for the third time in six months. Each incident write-up blamed a different team member, but the root cause never changed. No systemic fixes followed, so the outages kept happening.
This isn't a rare story; it's common when post-mortems are treated as a formality or finger-pointing exercise. Most organizations do create post-mortem reports after big incidents, but they skip the hard work of systemic change. The result: the same failures repeat.
The Brutal Data
Here's what empirical research tells us about why incidents happen and keep happening:
80% Are Self-Inflicted
A 2024 study of 26 major fintech incidents found that 80% of incidents stemmed from internal changes: deployments, config updates, and other modifications that weren't tested or controlled properly.¹ In other words, most outages aren't caused by external forces or unforeseeable circumstances. They're self-inflicted wounds from our own actions.
69% Lack Early Warning
The same study showed 69% of incidents lacked proactive alerts, meaning teams only discovered the problem after damage was done.¹ These weren't subtle, hard-to-detect issues. They were problems that could have been caught if proper monitoring and alerting systems were in place.
Most Learning Efforts Fail
Despite formal incident processes, recurring IT incidents persist across most organizations. This indicates that teams aren't truly learning or improving systems; they're going through the motions without addressing underlying causes.
The Elite vs. Average Divide
The gap between average and elite teams is enormous when it comes to incident management:
Elite Teams: The Prevention Masters
High-performing organizations virtually eliminate repeat failures. In top "Site Reliability Engineering" cultures, major incidents rarely recur. Companies with continuous learning cultures (blameless post-mortems, proactive fixes) experience far fewer customer-impacting incidents than their peers.²
Elite teams prevent ~95% of repeat incidents. When they have an outage, they systematically address not just the immediate cause but the conditions that allowed it to happen. They ask: "What other ways could this type of failure occur?" and "How do we prevent the entire class of similar incidents?"
Average Teams: The Blame Cycle
Most teams get stuck in a reactive pattern:
- Incident happens
- Someone gets blamed
- Surface-level fix applied
- Same type of incident happens again
- Different person gets blamed
- Cycle repeats
Meanwhile, average teams remain reactive. They treat each incident as an isolated event rather than a symptom of systemic issues. Their post-mortems focus on "who" rather than "how," missing opportunities for meaningful improvement.
The Hidden Organizational Costs
The cost of this repetitive cycle extends beyond immediate downtime:
Financial Impact
- Gartner estimates downtime costs ~$5,600 per minute on average¹³
- For high-traffic services, costs can reach hundreds of thousands per hour
- Preventing even one repeat incident can far outweigh the engineering effort needed
Human Impact
- Engineers suffer from firefighting fatigue
- On-call burnout increases with repeated incidents
- Organizations with poor incident practices have 21% higher attrition²
- Talent chooses to work where they won't constantly fight the same fires
Opportunity Cost
- Engineering time spent on repeat incidents can't be spent on innovation
- Teams in blame cycles focus on covering themselves rather than improving systems
- Competitive advantage erodes when engineering capacity is consumed by preventable problems
Why Smart Teams Get Stuck
Even intelligent, well-intentioned teams fall into this trap. Three factors create the repetitive incident cycle:
The Blame Reflex
When something goes wrong, human nature seeks someone to hold responsible. This satisfies our need for closure but prevents deep analysis. We stop investigating once we find a scapegoat, missing the systemic factors that made the failure possible.
Hindsight Bias
After an incident, everything seems obvious. We think "we should have known" things that were actually unknowable beforehand. This false clarity leads to shallow fixes focused on individual awareness rather than system design.
The Action Item Void
Even when good insights emerge, execution often fails. Without clear ownership and tracking, follow-up tasks disappear into backlogs. Teams move on to new work, and the underlying vulnerabilities remain.
The Path Forward
The good news? This cycle isn't inevitable. Organizations that implement systematic approaches to incident learning see dramatic improvements:
- 50% reduction in repeat incidents within 12 months¹²
- 30% faster resolution times as teams get better at diagnosis¹²
- Significantly higher team satisfaction as firefighting decreases²
The key is moving from reactive blame to proactive system strengthening. This requires cultural changes (psychological safety), analytical changes (systems thinking), and process changes (action accountability).
Continue the series:
- Psychological Safety Infrastructure - Building blame-free cultures that surface truth
- Systems Thinking Over Person-Hunting - Finding root causes in complex systems
- Action Accountability That Sticks - Closing the execution gap on improvements
- Four-Phase Implementation Playbook - Step-by-step timeline from incident to improvement
- Convincing Skeptical Leaders - Getting executive support for transformation
Want the definitive framework? Read the Definitive Guide for detailed implementation steps, success stories, and metrics for measuring transformation.
Resources
- Definitive Guide (60 min) – canonical reference
