Run the Mortality Review Without the Blame Spiral
Use an After Action Review to convert a mortality event into specific operational learning.
The reframe: the review is not where you find a culprit; it is where you find the next better response. Start with intent Ask what the plan, SOP, alarm rule, or shift handover said should happen. This anchors the discussion in agreed work rather than personal memory. Rebuild the actual timeline Use logs, alarms, photos, DO readings, mortalities, calls, and crew observations. A timeline reveals gaps that no single person could see from their position. Explain the gap without simplifying it Most farm incidents are not caused by one mistake. They are usually a chain: a weak trigger, unclear ownership,…
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