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