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Three of Swords
"The Postmortem"
Swords · Process & Decisions▲ Upright -1
Something broke and you are looking directly at why. The Three of Swords is the blameless postmortem that is actually blameless, where someone writes down exactly what happened, including the part where the alert fired and everyone ignored it. This hurts to read. It is supposed to hurt. That is how you know it is honest.
▽ Reversed +1
The postmortem that never happened. The incident that got downgraded to 'expected behavior' because writing it up would implicate a decision someone important made. Reversed, the Three of Swords is the wound you refuse to examine, which means it will reopen on the next on-call rotation.