Post Mortem – Why Did it Happen

• It is important to document what happened and as much information about the incident as you can
• Good documentation of these events can lead to planning events that mitigate or eliminate them altogether
• It is sometimes necessary to evaluate documentation from several events to formulate a pro-active countermeasure

An Effective Post Mortem Analysis does not turn into a blame game! All participants must feel free to relate events as they happened, otherwise the solutions reached will not be effective