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Post-mortem

The incident doc that blames a person

The outage of 14 March

Shape
When it breaks
Plates
lede · timeline · worked · numbered
Why
A post-mortem is read by people who were not there, so the clock has to be legible: `timeline` and not a bulleted list, because the gaps are the story — eleven minutes to notice and ninety to understand is the finding. `worked` on the failing request rather than the healthy one. End with `numbered` changes that already happened, or this is a document about feelings.

For one hour and fifty-one minutes, about a third of requests failed. Nobody did anything wrong. A limit set in 2021 met a traffic pattern from 2026.

The hour and fifty-one minutes

  1. 09:14

    Deploy goes out

    Unremarkable, and not the cause

  2. 09:31

    First failures

    Below the alert threshold, so nothing fires

  3. 09:42

    A customer tells us

    Eleven minutes of failures nobody saw

  4. 11:12

    Cause found

    The connection pool, capped at fifty since 2021

  5. 11:16

    Resolved

    Cap raised. The fix took four minutes

Eleven minutes to notice, ninety to understand, four to fix. The middle number is the one worth arguing about.

What one failing request did

in

A request arrives and asks for a connection

waits

All fifty are busy. It queues30s timeout

out

It gives up and returns a 503, having done no work at all
  1. 1.

    The alert now fires on error rate, not error count. Shipped 15 March. This is what cost us the eleven minutes.

  2. 2.

    The pool size is derived, not written down. Shipped 18 March. It scales with the instance rather than with somebody's memory of 2021.

  3. 3.

    Connection saturation is on the dashboard. It was measurable all along. Nobody was looking at it.

This is a sample. To author the same thing about your own subject, just name it. Your assistant can read this template, and will write you the same document about what you know.

Using the Ario tools, make me the "Post-mortem"
template for the incident on the 3rd.
Show me the shape before you build anything.

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