<ol><li>Determine and rank the steps that should be taken to change the conditions that brought the incident in the first place.</li><li>To keep the learning review focused, prioritize and discuss these action items in separate follow-up meetings with the relevant people.</li><li>The facilitator must publish the learning review write-up as widely as possible. Both successes and failures should become part of institutional memory.</li><li>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.</li></ol>

Achieving Closure

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 learning process alleviates the discomfort of dealing with complex systems, but it costs in the long-term because you ignore the context of the incident and don’t address areas of fragility.

Don’t Trade Context For Convenience

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.

Build a Timeline

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.

The Hidden Harm Of Punishments

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

Setting Context To Maximize Learning

Most companies conduct postmortems at a project’s end to analyze and outline the factors that contributed to its failure. But this reflection, examination and evaluation might not be as useful as most wait for failures to conduct them and stop the analysis once the guilty are identified.Failures don't happen frequently enough to learn at the rate that’s needed to really thrive in a competitive environment. Learning reviews, on the other hand, aim to gather information and can be conducted after each experiment or iteration allowing improvements regardless of successes.

Postmortems vs Learning Reviews

The security incident at Symantec. The Volkswagen diesel emissions scandal. The market rigging allegations at Citigroup. In each of these cases, employees were singled out as the root causes for an organization's failures. Yet given the operational scale, complexity and clip of these companies, is it viable - or beneficial - to put the onus on specific individuals?

Don’t Trade Context For Convenience

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