Principle
Review a risky success, not only a visible failure
Success can be a bad process wearing a good outcome.
When it fits
- The result was good, but the path included an unsafe shortcut, surprising recovery, fragile assumption or unusual rescue.
When to avoid it
- Do not manufacture problems from every successful task. Use this when the path contains credible risk, surprise or recovery worth understanding.
Why it matters
Debrief the process when the outcome was better than the path deserved. Ask what had to go right, which adaptations rescued the work, what nearly failed and whether the same process would be acceptable if repeated. Preserve useful resilience as well as weaknesses. This prevents a lucky result from silently certifying a fragile method.
An example
A deployment succeeds only because one engineer manually spots an undocumented configuration mismatch. The release is successful, but the mismatch and rescue still deserve review.
Check your result
At least one process lesson is recorded independently of whether the final outcome was good or bad.
Keep this limit in mind
- Do not manufacture problems from every successful task. Use this when the path contains credible risk, surprise or recovery worth understanding.
Connected ideas
Useful withCapture the near miss while the evidence still exists
Evidence and sources
AHRQ recommends using briefings and debriefings as learning opportunities after routine work and after exceptionally poor or good outcomes.
A debrief can surface hypotheses and adaptations but does not establish causality by itself.
Engineering Safe Practices Affinity Group · Strategy 5: Incorporate Learning Opportunities into Routine Processes