When a major incident occurs in an IT environment, the immediate priority is to restore services as quickly as possible. However, the real value lies in the Post-Major Incident Review (PMIR), also known as a Post-Incident Review (PIR) or Post-Mortem. This review is crucial for identifying the root cause, learning from the event, and preventing similar issues from happening again. In this guide, we'll explore the importance of post-major incident reviews, how to conduct them effectively, and best practices for ensuring continuous improvement.
What is a Post-Major Incident Review (PMIR)?
A Post-Major Incident Review (PMIR) is a formal meeting or process that takes place after a major incident has been resolved. The goal is to analyse the incident, understand its causes, and assess the incident management process itself. It provides an opportunity for key stakeholders to review the incident, share insights, and document lessons learned.
The PMIR is critical for organizations because it:
- Uncovers Root Causes: Identifies the underlying technical and process failures that contributed to the incident. Or even the root cause for Problem Management to manage/investigate.
- Promotes Learning: Provides a structured environment for teams to learn from mistakes or missteps.
- Improves Future Response: Leads to actionable recommendations that enhance the organization’s ability to respond to and prevent future incidents.
- Ensures Accountability: Ensures that action items are assigned to responsible teams or individuals to prevent recurrence.
Key Components of a Successful Post-Major Incident Review
To ensure a productive PMIR, follow these key components:
- Incident Recap
Begin by providing a clear and concise recap of the major incident. This should include:
- Incident Description: What happened and when it started.
- Impact Summary: Affected systems, services, or users, along with the severity of the impact.
- Timeline: A chronological timeline from when the incident was detected to when it was resolved. Include important milestones such as when key decisions were made and actions were taken.
- Root Cause Analysis
Use structured methods such as the 5 Whys, Fishbone Diagrams, or Fault Tree Analysis to uncover the true root cause(s) of the incident. This should go beyond the immediate issue (e.g., "server failure") and identify why the failure occurred (e.g., "misconfigured server settings" or "inadequate testing before a software release").
Key questions to ask during the analysis:
- What were the contributing factors that led to the incident?
- Was there a process breakdown that allowed the issue to escalate?
- Could this issue have been prevented? How?
The Root Cause Analysis may not be covered in some organisations. This is often covered within the Problem Management process. And, the Problem Management Practice will use the PMIR to begin a Root Cause Analysis investigation. However, some organisations practice dual role for Major Incident Managers and Problem Managers. This is at your discretion to suit your specific environment.
- Incident Response Evaluation
Evaluate the efficiency and effectiveness of the incident response process. This includes:
- Response Time: How long did it take to detect and respond to the incident?
- Communication: Was communication between teams and stakeholders effective? Were the right people informed at the right time?
- Escalation: Was the escalation process followed properly? Were there any delays in engaging the right teams?
- Actionable Recommendations
Based on the root cause analysis and response evaluation, outline actionable recommendations for improving systems and processes. These could include:
- Process Improvements: Modifying or creating processes to ensure smoother incident handling in the future.
- Technology Enhancements: Implementing new tools or improving monitoring and alerting systems.
- Training: Providing additional training for teams to improve response capabilities.
Assign specific action items to individuals or teams, with clear deadlines for completion. It's important that these action items are tracked and reviewed in future meetings.
- Lessons Learned
Document key lessons learned during the incident. This section provides an opportunity for teams to reflect on what worked well and what didn’t. It encourages a culture of continuous improvement and collaboration across departments.
- Follow-Up Actions
Finally, schedule follow-up meetings or reviews to ensure that recommendations and action items are being implemented. Regular follow-ups prevent issues from falling through the cracks and demonstrate the organization's commitment to improvement.
Best Practices for Conducting a Post-Major Incident Review
To ensure that your PMIR is thorough and effective, consider these best practices:
- Create a Blame-Free Environment
The purpose of the PMIR is to learn and improve, not to assign blame. Encourage transparency and open communication during the review, making it clear that the focus is on understanding what went wrong and preventing future incidents, not on pointing fingers.
- Involve All Relevant Stakeholders
Ensure that everyone involved in the incident or affected by it participates in the review. This includes technical teams (IT, DevOps, network engineers), management, and possibly business stakeholders. Including a diverse range of perspectives helps uncover insights that may be missed by a single team.
- Keep it Structured
Use a formal agenda to guide the PMIR process. This ensures that the discussion stays focused and covers all key aspects of the incident. It’s important to allocate enough time for each section (e.g., incident recap, root cause analysis) without rushing.
- Document the Review
Document all findings, discussions, and action items from the PMIR. This documentation should be stored in a centralized location where it can be accessed by relevant teams in the future. Keeping a well-organized log of incident reviews helps identify recurring patterns and long-term issues.
- Turn Insights into Action
A PMIR is only valuable if it leads to actionable improvements. Be diligent about tracking action items and holding teams accountable for implementing them. Use project management or incident tracking tools to ensure that recommendations are executed and monitored.
Common Challenges in Post-Major Incident Reviews
While PMIRs are an invaluable tool for improvement, they can come with challenges:
- Time Constraints: In fast-paced environments, it can be difficult to find time for an in-depth review. However, skipping a PMIR can result in missed opportunities for improvement.
- Incomplete Information: Sometimes, teams may not have all the data needed for a thorough analysis. Ensure proper logging and monitoring are in place during incidents to gather sufficient data for the review.
- Blame Culture: If a blame culture exists within an organization, team members may be reluctant to share insights or admit mistakes. Leaders must foster a safe environment that encourages openness.
Conclusion
Post-Major Incident Reviews are a critical component of Major Incident Management. They provide organizations with a structured way to analyse incidents, learn from them, and improve their response capabilities. By fostering a culture of continuous improvement, conducting thorough root cause analysis, and implementing actionable recommendations, organizations can reduce the likelihood of future incidents and enhance overall system reliability.
By committing to regular and detailed PMIRs, your organization not only mitigates risks but also builds resilience, ensuring that major incidents lead to lasting improvements rather than recurring problems.