Learning from failure.
WHAT TO PRODUCE
A short written record.
WHAT IT SHOULD CONTAIN
What happened, with a timeline What the impact was What the cause was Why it was not prevented Why it was not detected sooner What will change
WHAT TO FOCUS ON
The system, not the person.
WHAT TO ASK
What made this possible? What would have caught it earlier? What made recovery slow?
WHAT NOT TO CONCLUDE
That someone should have been more careful.
WHY
That produces no change, and discourages reporting.
WHAT TO MEASURE
Time to detect Time to respond Time to resolve
WHAT THOSE REVEAL
Where the process is weak.
A long time to detect is a monitoring problem, not a cause problem.
WHAT TO PRODUCE
A small number of specific actions, each with an owner and a date.
WHAT NOT TO PRODUCE
A long list nobody completes.
WHAT TO DO AFTERWARDS
Check that the actions were taken.
