Correction of Errors (COE)

Overview

A Correction of Errors (COE) is a blameless post-incident document that analyzes what happened, why it happened, and what mechanisms will prevent recurrence. The goal is not to assign blame—it is to improve the system so the same class of failure cannot happen again. COEs produce mechanisms (automated safeguards), not promises ("we'll be more careful"). Every COE must result in concrete action items with owners and due dates that make the system more resilient.

When to Use

• After any incident that reveals a systemic gap (even if low severity)
• After near-misses that could have been highly severy with slightly different conditions
• When the same type of failure recurs (even at low severity)
• When requested by leadership for learning purposes

Agent Persona

Load agents/coe-reviewer.md when reviewing a COE. Use it to enforce blameless analysis, timeline accuracy, root-cause depth, mechanism quality, and concrete action items with owners and dates.

Amazon Context

Amazon's COE process is one of its most powerful learning mechanisms. The document is written by the team that experienced the incident, reviewed by senior leadership, and shared broadly for organizational learning. The key insight: people don't cause failures—systems allow failures. If a single person's mistake can cause a customer-impacting incident, the system lacks sufficient safeguards. COEs that conclude "the engineer should have been more careful" are rejected. COEs that conclude "we will add an automated check that prevents this class of error" are accepted.

The Process

Timeline (Within 24 hours of incident)

1. Incident Commander or on-call engineer drafts initial timeline
2. All participants review and add their perspective
3. Timeline must include:
   • Exact times (timezone-explicit) for each event
   • What was observed at each point
   • What actions were taken and by whom
   • What information was available (and what wasn't)
   • When customer impact started and ended

5 Whys Analysis

Start with the customer impact and ask "why" until you reach systemic root causes:

1. Why were customers affected? → Service returned 500 errors for 23 minutes
2. Why did the service return 500s? → Database connections were exhausted
3. Why were connections exhausted? → A code change introduced a connection leak
4. Why wasn't the leak caught? → Integration tests don't measure connection pool behavior
5. Why wasn't it detected earlier? → No alarm on connection pool utilization

Root causes from this example:

• Missing test coverage for resource management
• Missing operational alarm for connection pool health
• Code review didn't catch the missing connection close

Writing the COE

Section 1: Summary

• One paragraph: What happened, when, customer impact, duration
• Severity level and scope (customers affected, regions, revenue impact)

Section 2: Customer Impact

• What did customers experience?
• How many customers were affected?
• What was the duration of impact?
• Were there any data loss or consistency issues?

Section 3: Timeline

• Minute-by-minute account of the incident
• Include detection time, mitigation actions, resolution time

Section 4: Root Cause Analysis (5 Whys)

• The complete 5 Whys chain(s)
• Identify contributing factors vs. root causes
• Multiple root cause chains are common and expected

Section 5: Action Items

• Each action item has: description, owner (individual), due date, status
• Categories: Immediate (7 days), Short-term (30 days), Long-term (90 days)
• Must include at least one mechanism (automated safeguard)
• "Be more careful" is never an acceptable action item

Section 6: Lessons Learned

• What went well during the incident response?
• What could have been done better?
• Are there broader organizational lessons?

COE Review

1. Team reviews internally first (ensures accuracy)
2. Manager reviews for completeness and mechanism quality
3. Senior leadership reviews for organizational learning opportunities
4. Shared with broader organization (relevant teams, COE digest)

Action Item Tracking

• All action items entered in tracking system with due dates
• Reviewed in the recurring Metrics Review cadence
• Overdue items escalated to manager, then skip-level
• COE not "closed" until all action items are completed
• Quarterly review of action item completion rates

Mechanisms Over Good Intentions

Common Rationalizations

Red Flags

• COE that blames an individual ("John deployed without checking")
• Action items that are all "be more careful" or "remember to check"
• No mechanism-based action items
• COE written 2+ weeks after the incident (memory fades)
• Action items with no owner or no due date
• Same root cause appearing in multiple COEs (action items not effective)
• COE never shared beyond the immediate team
• Action items never completed (marked "will not fix")
• Timeline missing key decision points
• No mention of what went well (discourages future good behavior)

Verification

• Timeline is complete with exact timestamps
• 5 Whys reaches systemic root causes (not human error)
• At least one action item creates an automated mechanism
• Every action item has an owner and due date
• COE reviewed by manager and senior leadership
• COE shared with relevant broader teams
• Action items tracked in operational review
• No blame language in the document
• Similar incident from the past? Check if previous COE actions were completed

Implementation Memory Capture

After corrective actions are defined, check whether any action item is an implementation-level corrective action (something that should change how code is written in future builds — not an org/process/people action). If so:

1. Read skills/implementation-memory/SKILL.md.
2. Generate a self-reflection: "What implementation practice would have prevented or mitigated this incident? What general rule should apply to future builds?"
3. Extract up to 2 candidate learnings from implementation-level action items.
4. Present candidates to the user for Accept / Reject / Edit.
5. Apply admission checks and rejection rules before writing to .bla/implementation-memory.md.

If no implementation-level action item exists (all actions are org/process/infra), skip this step silently.

Tenets

1. Blameless means systemic. If your conclusion requires a person to have done something differently, dig deeper into why the system allowed it.
2. Mechanisms over promises. "We will" is not a solution. "The system will automatically" is a solution.
3. Every incident is a gift. It revealed a weakness you didn't know about. Fix it before it happens again at larger scale.
4. Share broadly. The same failure patterns exist across teams. One team's COE prevents another team's severity.
5. Action items are commitments. They are not suggestions. They have owners, dates, and tracking. Incomplete action items mean the COE failed.