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...

Blame and biases — such as hindsight bias — give us a convenient story about what happened in any negative situation. To the extent that a story feels comfortable, we believe that it's true but when we get to that convenient point we stop learning.

Skipping the learnin...

• 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.
• Focus on the context of the incident and assure everyone that no...

• Ask each individual involved to share what they knew, when they knew it and how they knew it. There are a few points to emphasize:

• Ask for descriptions without explanations
• Ask for timestamps (or estimates) of when they knew what they knew
• Systematically as...

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....