How to do an unscheduled post-mortem

After hitting an unanticipated issue or approval escalation, we should complete an unscheduled post-mortem to help us improve our processes and avoid making the same mistake twice.

In the spirit of "don't make the same mistake twice", after hitting a significant issue, a repeated issue, or an escalated approval issue we conduct an unscheduled post-mortem.

This should take 5-10 minutes to prepare. Following the issue, the person with the most knowledge of the issue should send an email to the group with the following summary:

  1. What was the issue?

  2. What could have been done to improve the outcome?

  3. What are we changing in our process and documentation (if anything) it improve future outcomes?

The people receiving the email should set a 90-day timer on the email and confirm in 90 days that the process changes were successful in preventing the issue from happening again. In this way, we avoid the problem of making the same mistake twice. Instead, we continually iterate and improve our processes.

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