The key to learning from your mistakes is to document your failures by performing aroot-cause analysis and writing up a “postmortem”.
A properpostmortem should always contain an explanation of what was learned and what isgoing to change as a result of the learning experience. Then, make sure that the post‐mortem is readily accessible and that the team really follows through on the proposedchanges.
- A brief summary of the event
- A timeline of the event, from discovery through investigation to resolution
- The primary cause of the event
- Impact and damage assessment
- A set of action items (with owners) to fix the problem immediately
- A set of action items to prevent the event from happening again
- Lessons learned