Death is Truth: Why Post-Mortems Work
How to successfully perform the Rite of AshkEnte
by Danver Braganza on 2022-12-16
In Terry Pratchett’s vividly comic Discworld series is described a magical rite that is invoked whenever wizards need an answer to a question that is beyond their knowledge. The Rite of AshkEnte summons the personification of Death himself, and binds him within a circle where the wizards interrogate him. Death almost always has the answers, presumably because against him no lock will hold nor fastened portal bar.
One of the reasons I love the Discworld so much is how it manages to distill mythological tropes into recognizable shapes. The link between death and divination is established in multiple cultures. Practitioners summoned spirits from beyond the grave for questioning, or sacrificed the living to perform divination via their entrails. In myths or fables, the God or Angel of Death would appear in person to impart foreknowledge, usually of impending doom but also descriptions of correct character. Today, more modern audiences are still fascinated by tales of how forensic autopsies lead to the capture of murderers.
I think there connecting death with the experience of the ultimate reality is justified experimentally. Some part of this is due to our extreme loss-aversion as a species and as individuals. Because our own death symbolizes a near-total loss, it’s natural to find it near-maximally emotionally salient. From a less emotional and more analytical perspective taking careful note of deaths has value precisely because Death cannot be cheated indefinitely. Therefore, every experience with death is an experience to get incontrovertible, positive evidence about reality.
In an engineering organization that is operating successfully, i.e. alive, there should be a direct flow of value delivered to users. Picture this value as a network of pure blue rivulets flowing down rolling mountainside. All those downstream enjoy the clean, life-giving water, and the greater the flow, the more they enjoy.
However, just as water doesn’t always take the optimal path and can get stuck in ponds or lakes, so too can the engineering pipeline lose its momentum in false starts, vanity projects or initiatives that don’t pay back their return on investment. In cases like these, it can take a long time for a project to naturally die. The resources of the rest of the organization can act as life support, sustaining existence despite it being a drain of time and effort. There might even be a willful blindness to this drain due to perverse incentives within the organization. Nevertheless, refusing to acknowledge Death only puts more of the wider system at risk of falling under his domain.
Eventually, Death takes his due. A network of rivulets that appear to be robust at first, will suddenly become polluted or dry up entirely. Perhaps a technical or organizational risk that was not managed adequately blows up, taking a section of the flows of value with it. While it may not be fair to say that the system was intentionally ignoring the risk before the failure, continuing to ignore the risk afterwards is a waste of knowledge dearly bought by contact with the Realm of Death.
The death of a project or product, is in fact a wake-up call. Whenever it happens, all the survivors have a deep opportunity to learn. Not just to prevent future failures of the same kind, but to pattern-match across all the value flows to see where more such risks might be lurking.
The best way to interrogate Death is to perform an honest, critical and decisive Post Mortem after the fact. This is our version of the Rite of AshkEnte, where the spectre is bound and we have a chance to face our truth.
Without honesty, the same biases and misaligned incentives that caused the organization to ignore the risks in the first place will continue to manifest themselves. Because honesty is such an important criteria for the post mortem, post mortems must be blameless. This decreases, as much as possible, the incentive to lie to protect one’s own skin.
Blamelessness can only remove the incentive to lie to protect oneself or others. As it’s said, “It is difficult to get a man to understand something when his salary depends upon his not understanding it.”1 A willful blindness to a systemic risk might still persist. This is where it is necessary to be critical of what you hear. The Five Whys analysis tool prescribes questioning “Why?” to every answer, at least 5 times. This gives you a chance to root out some of these blind spots, if people have the insight–and the courage–to ask the right questions.
Finally, decisive follow-through is important to ensure that the improvements identified by the post mortem are actually taken. Having adequate buy-in and methods of accountability are necessary to make sure that help is obtained whence it’s needed. And if aid is not forthcoming, that may be cause for reflection–is the flow of value under discussion actually valuable enough to justify this effort? Is it adequately visible to all decision-makers?
In the end, Death comes to us all. Before then, we have many opportunities to meet him in his many guises, and to learn from him what lessons we can. 4 ccs of mouse blood not needed.
- This quote is attributed to Upton Sinclair, a quick Google search tells me. ↩︎
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