Postmortem

[Postmortem]

Status: Opened | Completed
Date: YYYY-MM-DD

Authors:

Project / Service:

Summary

Brief, factual summary of what happened, the impact, and the outcome. Avoid blame or judgment.

Illustrative example (literary): Romeo and Juliet fell in love despite a long-standing feud between their families. A secret relationship led to misunderstandings, cascading failures, and ultimately the loss of both lives.

Root cause

Describe the underlying systemic causes that led to the incident. Focus on why the system allowed this to happen, not on individual mistakes.

• Technical factors
• Process gaps
• Communication failures
• Organizational constraints

Illustrative example (literary):

• Unresolved historical conflict between the Montague and Capulet families.
• Critical message from Friar Laurence was not delivered in time.
• Decisions were made without validation or shared visibility.

Investigation

Describe how the incident was investigated.

• Initial signals or alerts
• Early hypotheses (including incorrect ones)
• Evidence collected
• How the correct cause was identified

Illustrative example (literary):

• Initial signals: rumors in Verona about secret meetings.
• Incorrect hypothesis: the relationship was harmless friendship.
• Evidence: testimonies, exchanged letters, sightings.
• Correct discovery: a secret marriage facilitated by Friar Laurence.

Corrective actions

Actions taken to resolve the incident or mitigate its effects.

• Immediate fixes
• Emergency actions
• Recovery steps

Illustrative example (literary):

No corrective action was possible after the outcome. The families acknowledged the destructive nature of the feud.

Preventive actions

Actions intended to prevent similar incidents in the future.

• Technical changes
• Process improvements
• Communication safeguards

Illustrative example (literary):

• Establish formal communication channels between families.
• Introduce redundancy and confirmation for critical messages.
• Promote structured interaction programs to reduce hostility.

Timeline

Chronological sequence of key events.

• Detected - Initial signal or anomaly observed
• Investigating - Active investigation started
• Identified - Root cause understood
• Mitigation attempted - Actions taken to reduce impact
• Resolved - Incident closed

Illustrative example (literary):

• Detected - Romeo and Juliet meet.
• Investigating - Families monitor rumors in Verona.
• Identified - Secret marriage uncovered.
• Mitigation attempted - Friar Laurence proposes a reconciliation plan.
• Resolved - Juliet awakens, finds Romeo dead, and dies.

Lessons learned

(Optional but recommended)

• What surprised us?
• What assumptions were incorrect?
• What will we do differently next time?

Action items