To extract a full account of the incident, remove blame and punishment on an organizational level from your retrospectives. You get there easier by reducing the fear and biases that creep in during the investigation of failures, and by choosing reconciliation and immunity over retribution.

Often, the conditions that lead to the negative outcome would still be there even if you removed the guilty individuals. And if the guilty are fired, you lose those who are better placed to help you learn from the incident.

• Repeatedly remind your team that they’re part of a learning organization to make them focus on learning.
• Remind your people that you are all operating within complex systems, thus failures can be unpredictable.
• Failure is a normal part of the functioning of complex systems.
• Seek to understand what goes wrong and what goes right, to make more resilient systems.
• Look for the conditions that allowed a particular situation to manifest, and accept that not all of them are knowable or fixable.
• Human errors are a symptom of trouble within the system, not the cause. 
• Educate everyone on cognitive biases and keep an eye out for them.

A timeline is an account of what happened by the people who were involved and impacted. Create a timeline with input from as many people from diverse points of view. With some training, anyone in the organization can do it.

A good timeline shows not just what happened, but serves as a reference point to keep the review on track. It should capture what people were thinking at the time it was happening instead of reflecting what happened from the biased perspective of the present.

1. Determine and rank the steps that should be taken to change the conditions that brought the incident in the first place.
2. To keep the learning review focused, prioritize and discuss these action items in separate follow-up meetings with the relevant people.
3. The facilitator must publish the learning review write-up as widely as possible. Both successes and failures should become part of institutional memory.
4. If the incident negatively impacted people, consider using the 3 Rs to structure the writeup. The Rs stand for ‘Regret, Reason, and Remedy’ as it provides a straightforward formula for a meaningful, satisfying apology.