Major Problem Reviews — Learning from Your Most Significant Failures
Every Major Incident Deserves a Major Problem Review — Here's How to Do It Right
When to Conduct a Major Problem Review
Team members should carry out in-depth reviews of major problems.
When a Major Incident occurs, a problem should always be raised. After resolution, team members should carry out in-depth reviews of major problems.
What a Major Problem Review Covers
A major problem review should cover:
What happened: The incident timeline and events
Why it happened: Root cause analysis
What worked: What went well in the response
What could have been better: Areas for improvement
What we learned: Key lessons and insights
What we'll do differently: Action items and follow-up
The Major Problem Review Process
Step 1: Schedule Promptly
Schedule the review within 5 business days of the incident. Quickness matters—details are fresher, and the incident is still top of mind.
Step 2: Gather Participants
Include:
Incident Commander (if used)
Technical responders
Problem Manager
Service owners
Management (for significant incidents)
Step 3: Prepare the Review
Collect:
Incident timeline
Communications
Actions taken
Root cause analysis
Resolution details
Step 4: Conduct the Review
Review the incident timeline
Discuss the root cause
Identify what worked well
Identify areas for improvement
Document action items
Step 5: Follow Up
Assign owners to action items
Set due dates
Track completion
Share learnings
Key Questions to Ask
Area
Questions
Detection
How was the incident detected? Could it have been detected faster?
Response
Was the response effective? What could have been better?
Communication
Were stakeholders informed appropriately?
Resolution
Was the resolution effective? Could it have been faster?
Prevention
What could prevent recurrence?
Learning
What can we learn from this incident?
Major Problem Review Template
Incident Summary
Date and time
Duration
Severity
Impact
Timeline
When events occurred
Key decisions
Communications
Root Cause
What caused the incident
Contributing factors
What Worked
What went well
What Could Have Been Better
Areas for improvement
Lessons Learned
Key insights
Action Items
#
Action
Owner
Due Date
1
Action
Name
Date
Conclusion
Major problem reviews are essential for learning from significant failures. By conducting thorough reviews, organizations can prevent recurrence, improve response, and build resilience.
Action Items for Your Organization
Establish a major problem review process
Create a major problem review template
Schedule reviews promptly after major incidents
Assign action items with owners and due dates
Share learnings across the organization
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01 Oct 2024