Conduct a post-miss debrief that finds ownership gaps and produces new commitments.
Blame asks who is guilty; accountability asks what must change and who owns it. Start With Owned Facts Name what happened, who was accountable for the outcome, and what impact it created. Keep the first pass descriptive so the room can stay in problem-solving mode. Map The Role Gap Use RACI to find where the work system broke: unclear accountable owner, overloaded responsible person, consulted expert missing, or informed group surprised too late. End With New Promises A debrief should produce commitments, not slogans. Each action needs a performer, deliverable, deadline, and acceptance standard.
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