Operational Postmortem

A structured after-action review conducted within 72 hours of a significant operational failure that identifies the root cause of the failure, the earliest point at which it could have been detected and corrected, the specific process or structural change required to prevent recurrence, and the owner responsible for implementing that change.

The postmortem is not a blame-allocation exercise. It is a systems analysis exercise conducted under the assumption that the people involved acted correctly given the information they had.