Conducting and documenting a lessons-learned review after a crisis

Contents of the template for the lessons-learned review after a crisis

• A scoping sheet: event analysed, commissioning party, facilitator, participants, timetable and rules governing written records.
• Conduct principles and a list of sources: incident log, decision register, system logs, messages issued.
• A chronology of facts and a chronology of knowledge, to measure what the decision-makers knew at each moment.
• One sheet per decision: triggering information, time elapsed, level that decided, options considered, effect observed.
• A rating of the system from 1 (failure) to 5 (functioning as expected), then one sheet per gap identified.
• The running order of the collective session, an action plan with verifiable criteria and a summary for reporting back.

When to undertake the process

The process takes place once the situation has stabilised, within a time frame that preserves the participants’ memory. It also applies to incidents brought under control and to near misses. These events indeed reveal the same weaknesses at lower cost. Executive management and steering committees are its primary users, in particular when they commission the exercise.

Instructions for use

First, the commissioning party approves the scoping and appoints a facilitator other than the person who directed the crisis unit. Next, the team gathers the sources and conducts individual interviews before the collective session. It then establishes the two chronologies, analyses the decisions and rates the system. Finally, the collective session validates the gaps retained and the first lines of action, which the governance body then examines.

Expected outcome

The lessons-learned review after a crisis results in a report that brings together context, chronologies, gaps and action plan. Each action has an owner, a deadline and a verification method: document check, test or exercise. Plans, procedures and templates then undergo a versioned update.

Key facts

Limitations

The template is a methodological aid; it produces neither a legal characterisation of the facts nor an assessment of responsibilities. Furthermore, adaptation to the specific case, the conduct of interviews, review and follow-up fall within consultations and packages. No representation falls within its scope. Finally, the lessons-learned review after a crisis replaces neither the investigations nor the notifications required by the applicable regulations.

Further reading: Governance & Dispute Resolution; ISO 22361:2022, Security and resilience – Crisis management – Guidelines (ISO).