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.

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.

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.

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 mus...

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.