A Post Incident Review Review
summary
Describes a post-incident practice that drops no root cause and no action items and instead runs a blame aware after-action review plus either a one-hour lightweight incident record or a full incident report that can take a day or more; uses timelines, screenshots and a present-tense narrative, publishes recommendations (not enforced tasks), tracks reliability via SLOs not MTTR, stores reports in a Wiki, and finds this yields organizational learning in a 1,000+ person regulated environment.
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chapters (18)
- 0:00Intro
- 1:53Hands on Guides
- 8:28PIR Styles
- 13:01Rasmussen's Safety Mod
- 15:48Dekker's Tunnel
- 18:06Causal Map
- 19:35James Reason's 'Swiss Cheese Model' of Accident Causation
- 26:35Record vs Report
- 29:56Narrative
- 30:39Debrief
- 31:37Walking the Timeline
- 33:13Lessons
- 34:16Brainstorming
- 35:01Recommendations
- 39:41Metrics
- 40:35Service Level Objectives
- 41:25Improvements
- 42:43What's next?
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